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Kain MJW, Reece NL, Parry CM, Rajahram GS, Paterson DL, Woolley SD. The Rapid Emergence of Hypervirulent Klebsiella Species and Burkholderia pseudomallei as Major Health Threats in Southeast Asia: The Urgent Need for Recognition as Neglected Tropical Diseases. Trop Med Infect Dis 2024; 9:80. [PMID: 38668541 PMCID: PMC11054678 DOI: 10.3390/tropicalmed9040080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024] Open
Abstract
The World Health Organization (WHO)'s list of neglected tropical diseases (NTDs) highlights conditions that are responsible for devastating health, social and economic consequences, and yet, they are overlooked and poorly resourced. The NTD list does not include conditions caused by Gram-negative bacilli (GNB). Infections due to GNB cause significant morbidity and mortality and are prevalent worldwide. Southeast Asia is a WHO region of low- and middle-income countries carrying the largest burden of NTDs. Two significant health threats in Southeast Asia are Burkholderia pseudomallei (causing melioidosis) and hypervirulent Klebsiella pneumoniae (HvKp). Both diseases have high mortality and increasing prevalence, yet both suffer from a lack of awareness, significant under-resourcing, incomplete epidemiological data, limited diagnostics, and a lack of evidence-based treatment. Emerging evidence shows that both melioidosis and HvKp are spreading globally, including in high-income countries, highlighting the potential future global threat they pose. In this article, we review both conditions, identifying current trends and challenges in Southeast Asia and areas for future research. We also argue that melioidosis and HvKp merit inclusion as NTDs, and that mandatory global surveillance and reporting systems should be established, and we make an urgent call for research to better understand, detect, and treat these neglected diseases.
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Affiliation(s)
| | | | - Christopher M. Parry
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK;
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Giri Shan Rajahram
- Department of Medicine, Queen Elizabeth II Hospital, Kota Kinabalu 88300, Malaysia
- Infectious Diseases Society, Kota Kinabalu Sabah-Menzies School of Health Research, Clinical Research Unit, Kota Kinabalu 88994, Malaysia
| | - David L. Paterson
- ADVANCE-ID Network, Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119077, Singapore
- Infectious Diseases Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Stephen D. Woolley
- Institute of Naval Medicine, Alverstoke, Hampshire PO12 2DL, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK;
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals Foundation NHS Trust, Liverpool L7 8YE, UK
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Brachaczek P, Lonc A, Kretzschmar ME, Mikolajczyk R, Horn J, Karch A, Sakowski K, Piotrowska MJ. Transmission of drug-resistant bacteria in a hospital-community model stratified by patient risk. Sci Rep 2023; 13:18593. [PMID: 37903799 PMCID: PMC10616222 DOI: 10.1038/s41598-023-45248-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/17/2023] [Indexed: 11/01/2023] Open
Abstract
A susceptible-infectious-susceptible (SIS) model for simulating healthcare-acquired infection spread within a hospital and associated community is proposed. The model accounts for the stratification of in-patients into two susceptibility-based risk groups. The model is formulated as a system of first-order ordinary differential equations (ODEs) with appropriate initial conditions. The mathematical analysis of this system is demonstrated. It is shown that the system has unique global solutions, which are bounded and non-negative. The basic reproduction number ([Formula: see text]) for the considered model is derived. The existence and the stability of the stationary solutions are analysed. The disease-free stationary solution is always present and is globally asymptotically stable for [Formula: see text], while for [Formula: see text] it is unstable. The presence of an endemic stationary solution depends on the model parameters and when it exists, it is globally asymptotically stable. The endemic state encompasses both risk groups. The endemic state within only one group only is not possible. In addition, for [Formula: see text] a forward bifurcation takes place. Numerical simulations, based on the anonymised insurance data, are also presented to illustrate theoretical results.
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Affiliation(s)
- Paweł Brachaczek
- Faculty of Mathematics, Informatics and Mechanics, University of Warsaw, Banacha 2, 02-097, Warsaw, Poland
| | - Agata Lonc
- Faculty of Mathematics, Informatics and Mechanics, University of Warsaw, Banacha 2, 02-097, Warsaw, Poland
| | - Mirjam E Kretzschmar
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometry, and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical Faculty of the Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Johannes Horn
- Institute for Medical Epidemiology, Biometry, and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical Faculty of the Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Andre Karch
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Konrad Sakowski
- Institute of Applied Mathematics and Mechanics, University of Warsaw, Banacha 2, 02-097, Warsaw, Poland.
| | - Monika J Piotrowska
- Institute of Applied Mathematics and Mechanics, University of Warsaw, Banacha 2, 02-097, Warsaw, Poland
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Weber A, Neffe L, Diaz LAP, Thoma N, Aghdassi SJS, Denkel LA, Maechler F, Behnke M, Häussler S, Gastmeier P, Kola A. Analysis of transmission-related third-generation cephalosporin-resistant Enterobacterales by electronic data mining and core genome multi-locus sequence typing. J Hosp Infect 2023; 140:96-101. [PMID: 37562589 DOI: 10.1016/j.jhin.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND To contain intra-hospital transmission of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), contact isolation precautions are recommended. AIM To quantify transmissions of 3GCR Escherichia coli and 3GCR Klebsiella pneumoniae within a hospital. METHODS An automated outbreak detection system (AODS) was used to identify clusters (N≥2) of 3GCR Enterobacterales for the years 2016, 2018 and 2020. Clusters were defined by phenotypic agreement of microbiological results and spatial and temporal relationship. Core genome multi-locus sequence typing (cgMLST) was used to confirm whether the cluster isolates were transmitted between patients. FINDINGS A total of 4343 3GCR E. coli and 1377 K. pneumoniae isolates were analysed. Among the 3GCR E. coli isolates, the AODS identified 304 isolates as cluster isolates, the median cluster size was two (range: 2-5). The cgMLST analysis revealed that a total of 23 (7.5%) 3GCR E. coli cluster isolates were transmission-associated, of which 20 isolates (87%) were detected in intensive care patients. Among the 3GCR K. pneumoniae isolates, the AODS identified 73 isolates as cluster isolates, the median cluster size was two (range: 2-4). CgMLST revealed that 35 (48%) 3GCR K. pneumoniae cluster isolates were transmission associated, of which 27 isolates (77%) were detected in intensive care patients. CONCLUSION For 3GCR K. pneumoniae, cgMLST confirmed the AODS results more frequently than for 3GCR E. coli. Therefore, contact isolation precautions for 3GCR K. pneumoniae may be appropriate on intensive care units, but only in certain circumstances, such as outbreaks, for Enterobacterales with lower transmissibility, such as E. coli.
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Affiliation(s)
- A Weber
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - L Neffe
- Helmholtz Centre for Infection Research, Department of Molecular Bacteriology, Braunschweig, Germany
| | - L A P Diaz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - N Thoma
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - S J S Aghdassi
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Programme, Berlin, Germany
| | - L A Denkel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - F Maechler
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - M Behnke
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - S Häussler
- Helmholtz Centre for Infection Research, Department of Molecular Bacteriology, Braunschweig, Germany; TWINCORE, Centre for Experimental and Clinical Infection Research, A Joint Venture of the HZI and the Hannover Medical School, Hannover, Germany
| | - P Gastmeier
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - A Kola
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.
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Karampatakis T, Tsergouli K, Roilides E. Infection control measures against multidrug-resistant Gram-negative bacteria in children and neonates. Future Microbiol 2023; 18:751-765. [PMID: 37584552 DOI: 10.2217/fmb-2023-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
The increase in infections caused by multidrug-resistant (MDR) Gram-negative bacteria in neonatal and pediatric intensive care units over recent years is alarming. MDR Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii have constituted the main causes of the MDR Gram-negative bacteria problem. The implementation of infection control measures such as hand hygiene, cohorting of patients, contact precautions, active surveillance and environmental cleaning could diminish their spread. Recently, water safety has been identified as a major component of infection control policies. The aim of the current review is to highlight the effectiveness of these infection control measures in managing outbreaks caused by MDR Gram-negative bacteria in neonatal and pediatric intensive care units and highlight future perspectives on the topic.
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Affiliation(s)
| | - Katerina Tsergouli
- Microbiology Department, Agios Pavlos General Hospital, Thessaloniki, 551 34, Greece
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Health Sciences, Hippokration General Hospital, Thessaloniki, 546 42, Greece
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Morin-Le Bihan A, Le Neindre K, Dejoies L, Piau C, Donnio PY, Ménard G. Use of the quantitative antibiogram method for assessing nosocomial transmission of ESBL-producing Enterobacteriaceae in a French hospital. J Hosp Infect 2023; 135:132-138. [PMID: 36918068 DOI: 10.1016/j.jhin.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND ESBL-producing Enterobacteriaceae (eESBL) have a high prevalence in hospitals but real-time monitoring of nosocomial acquisition through conventional typing methods is challenging. Moreover, patient-to-patient transmission varies between the main species, namely Escherichia coli, and Klebsiella pneumoniae, then questioning the relevance of applying identical preventive measures. AIM To detect eESBL cross-transmission events (CTE) using combination of quantitative antibiogram with epidemiological data (combined-QA), and to rule on the effectiveness of standard or contact precautions for eESBL species. METHODS First, a validation set was used to confirm the relevance of the combined-QA by comparison to a combination of pulsed-field gel electrophoresis and epidemiological data (combined-PFGE). Secondly, a four-year retrospective analysis was conducted to detect eESBL-CTE in hospitalized patients. Two species were screened i.e. ESBL-E. coli (ESBL-Ec), and ESBL-K. pneumoniae (ESBL-Kp). During the study, only standard precautions were applied to ESBL-Ec patients whereas contact precautions were retained for ESBL-Kp. FINDINGS As a proof of concept, results between the two combined methods for the detection of CTE were identical for E. coli, and similar to at least 75% for K. pneumoniae. During the retrospective analysis, 722 patients with ESBL-Ec isolates and 280 with ESBL-Kp isolates were included. Nine CTE were identified for E. coli and 23 for K. pneumoniae, implying 20 (2.7%) and 36 (12.8%) patients, respectively. CONCLUSION The QA-combined method constitutes a rapid tool for epidemiological surveillance to detect CTE. In our hospital, standard precautions are sufficient to prevent acquisition of ESBL-Ec whereas contact precautions must be implemented to prevent acquisition of ESBL-Kp.
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Affiliation(s)
- Amélie Morin-Le Bihan
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France
| | - Killian Le Neindre
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France
| | - Loren Dejoies
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France
| | - Caroline Piau
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France
| | - Pierre-Yves Donnio
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France
| | - Guillaume Ménard
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France.
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Intestinal colonization with multidrug-resistant Enterobacterales: screening, epidemiology, clinical impact, and strategies to decolonize carriers. Eur J Clin Microbiol Infect Dis 2023; 42:229-254. [PMID: 36680641 PMCID: PMC9899200 DOI: 10.1007/s10096-023-04548-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
The clinical impact of infections due to extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacterales (Ent) has reached dramatic levels worldwide. Infections due to these multidrug-resistant (MDR) pathogens-especially Escherichia coli and Klebsiella pneumoniae-may originate from a prior asymptomatic intestinal colonization that could also favor transmission to other subjects. It is therefore desirable that gut carriers are rapidly identified to try preventing both the occurrence of serious endogenous infections and potential transmission. Together with the infection prevention and control countermeasures, any strategy capable of effectively eradicating the MDR-Ent from the intestinal tract would be desirable. In this narrative review, we present a summary of the different aspects linked to the intestinal colonization due to MDR-Ent. In particular, culture- and molecular-based screening techniques to identify carriers, data on prevalence and risk factors in different populations, clinical impact, length of colonization, and contribution to transmission in various settings will be overviewed. We will also discuss the standard strategies (selective digestive decontamination, fecal microbiota transplant) and those still in development (bacteriophages, probiotics, microcins, and CRISPR-Cas-based) that might be used to decolonize MDR-Ent carriers.
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Impact of Antibiotic Consumption on the Acquisition of Extended-Spectrum β-Lactamase Producing Enterobacterales Carriage during the COVID-19 Crisis in French Guiana. Antibiotics (Basel) 2022; 12:antibiotics12010058. [PMID: 36671259 PMCID: PMC9855120 DOI: 10.3390/antibiotics12010058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
(1) Background: During the COVID-19 outbreak, several studies showed an increased prevalence of extended-spectrum β-lactamase producing Enterobacterales (ESBL-PE) carriage in intensive care units (ICUs). Our objective was to assess the impact of antibiotic prescriptions on the acquisition of ESBL-PE in ICUs during the COVID-19 crisis. (2) Methods: We conducted an observational study between 1 April 2020, and 31 December 2021, in the medical-surgical ICU of the Cayenne General Hospital. We defined two periods: Period 1 with routine, empirical antibiotic use, and Period 2 with no systematic empiric antibiotic prescription. (3) Results: ICU-acquired ESBL-PE carriage was 22.8% during Period 1 and 9.4% during Period 2 (p = 0.005). The main isolated ESBL-PE was Klebsiella pneumoniae (84.6% in Period 1 and 58.3% in Period 2). When using a generalized linear model with a Poisson family, exposure to cefotaxime was the only factor independently associated with ESBL-PE acquisition in ICU (p = 0.002, IRR 2.59 (95% IC 1.42-4.75)). The propensity scores matching estimated the increased risk for cefotaxime use to acquire ESBL-PE carriage at 0.096 (95% CI = 0.02-0.17), p = 0.01. (4) Conclusions: Exposure to cefotaxime in patients with severe COVID-19 is strongly associated with the emergence of ESBL-PE in the context of maximal infection control measures.
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Moriyama Y, Doi A, Shinkai N, Nasu S, Mesaki K, Horii K, Ohmagari N, Hayakawa K. Clinical characteristics and risk factors for multidrug-resistant bacterial isolation in patients with international travel history. Am J Infect Control 2022; 51:660-667. [PMID: 36031036 DOI: 10.1016/j.ajic.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND International travelers are at risk of carrying resistant bacteria. It is critical to identify risk factors associated with multidrug-resistant organism (MDRO) colonization in travelers. METHODS A retrospective chart review observational study was conducted at two tertiary centers in Japan for inpatients who had been hospitalized or visited an outpatient clinic overseas within the previous 12 months. These patients underwent MDRO screening upon admission. To identify independent predictors for the isolation of MDROs, multivariable analyses were performed using logistic regression. RESULTS In total, 76 (35%) of the 216 patients were positive for MDROs at admission. The majority of bacteria detected in stool samples were extended-spectrum beta-lactamase-producing Escherichia coli (ESBLEC) (n = 67 [89%]). ESBLEC was detected in nearly 40% of patients who traveled to Asia. Travel to Asia was an independent risk factor for any MDRO and ESBLEC isolation. For non-ESBLEC MDRO isolation, a history of surgery abroad was an independent risk factor for detection. DISCUSSION AND CONCLUSIONS A history of hospitalization abroad has previously been found to be associated with MDRO colonization in travelers, which was not identified as a risk factor in this study. The risk factors for MDRO colonization were different between ESBLEC and non-ESBL MDROs.
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Affiliation(s)
- Yuki Moriyama
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Asako Doi
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Noriko Shinkai
- Department of Infection Control, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Seiko Nasu
- Department of Clinical Laboratory, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Kazuhisa Mesaki
- Department of Clinical Laboratory, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kumi Horii
- Infection Control and Prevention, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kayoko Hayakawa
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan.
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Genetic Characterization of Multidrug-Resistant E. coli Isolates from Bloodstream Infections in Lithuania. Microorganisms 2022; 10:microorganisms10020449. [PMID: 35208903 PMCID: PMC8880137 DOI: 10.3390/microorganisms10020449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 02/04/2023] Open
Abstract
Extraintestinal pathogenic Escherichia coli (ExPEC) isolates are a main cause of bloodstream infections. The aim of this study was to characterize 256 β-lactam–resistant, bacteremia-causing E. coli isolates collected from 12 healthcare institutions in Lithuania in 2014 and 2018. All isolates were identified as E. coli via MALDI-TOF MS and VITEK ®2. In addition, the isolates were analyzed for the presence of 29 resistance genes and 13 virulence genes, divided into phylogenetic groups (A, B1, B2, C, D, E, and F), and characterized using rep-PCR genotyping methods (BOX-PCR and (GTG)5-PCR). Analyzing the results of this study showed tetA-strB-sul2-TEM-NDM-strA-fosA-AIM-sul3-aadA-CTX-M-9 to be the most common resistance gene combination (67.2% of all isolates). Additionally, the most common virulence genes established were fimH (98.4% of all isolates), fyuA (91.8%), and traT (81.3%) and the most common gene combination was fuyA-fimH-iroN (58.6% of all isolates). Next, the isolates were separated into four phylogenetic groups: A, B1, B2, and F, where group A isolates were detected at a significantly higher frequency (79.3% of all isolates). Finally, a total of 235 genotyping profiles were established using rep-PCR methods, and all profiles were separated into fourteen genotypic clusters, with each cluster containing profiles with a variety of virulence and resistance genes not restricted to any specific cluster. The results of this study elucidate E. coli antimicrobial resistance patterns by highlighting the variability and diversity of resistance and virulence genes and providing phylogenetic classification, genetic profiling, and clustering data. These results may improve clinical control of multidrug-resistant infections in healthcare institutions and contribute to the prevention of potential outbreaks.
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Aslam B, Khurshid M, Arshad MI, Muzammil S, Rasool M, Yasmeen N, Shah T, Chaudhry TH, Rasool MH, Shahid A, Xueshan X, Baloch Z. Antibiotic Resistance: One Health One World Outlook. Front Cell Infect Microbiol 2021; 11:771510. [PMID: 34900756 PMCID: PMC8656695 DOI: 10.3389/fcimb.2021.771510] [Citation(s) in RCA: 161] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/29/2021] [Indexed: 01/07/2023] Open
Abstract
Antibiotic resistance (ABR) is a growing public health concern worldwide, and it is now regarded as a critical One Health issue. One Health’s interconnected domains contribute to the emergence, evolution, and spread of antibiotic-resistant microorganisms on a local and global scale, which is a significant risk factor for global health. The persistence and spread of resistant microbial species, and the association of determinants at the human-animal-environment interface can alter microbial genomes, resulting in resistant superbugs in various niches. ABR is motivated by a well-established link between three domains: human, animal, and environmental health. As a result, addressing ABR through the One Health approach makes sense. Several countries have implemented national action plans based on the One Health approach to combat antibiotic-resistant microbes, following the Tripartite’s Commitment Food and Agriculture Organization (FAO)-World Organization for Animal Health (OIE)-World Health Organization (WHO) guidelines. The ABR has been identified as a global health concern, and efforts are being made to mitigate this global health threat. To summarize, global interdisciplinary and unified approaches based on One Health principles are required to limit the ABR dissemination cycle, raise awareness and education about antibiotic use, and promote policy, advocacy, and antimicrobial stewardship.
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Affiliation(s)
- Bilal Aslam
- Department of Microbiology, Government College University Faisalabad, Faisalabad, Pakistan
| | - Mohsin Khurshid
- Department of Microbiology, Government College University Faisalabad, Faisalabad, Pakistan
| | | | - Saima Muzammil
- Department of Microbiology, Government College University Faisalabad, Faisalabad, Pakistan
| | - Maria Rasool
- Department of Microbiology, Government College University Faisalabad, Faisalabad, Pakistan
| | - Nafeesa Yasmeen
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, China
| | - Taif Shah
- Faculty of Life Science and Technology, Kunming University of Life Science and Technology, Kunming, China
| | - Tamoor Hamid Chaudhry
- Department of Microbiology, Government College University Faisalabad, Faisalabad, Pakistan.,Public Health Laboratories Division, National Institute of Health, Islamabad, Pakistan
| | | | - Aqsa Shahid
- Faculty of Rehabilitation and Allied Health Sciences, Riphah International University, Faisalabad, Pakistan
| | - Xia Xueshan
- Faculty of Life Science and Technology, Kunming University of Life Science and Technology, Kunming, China
| | - Zulqarnain Baloch
- Faculty of Life Science and Technology, Kunming University of Life Science and Technology, Kunming, China
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11
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Impact of the COVID-19 pandemic on the surveillance of antimicrobial resistance. J Hosp Infect 2021; 117:147-156. [PMID: 34562548 PMCID: PMC8457641 DOI: 10.1016/j.jhin.2021.09.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/05/2021] [Accepted: 09/16/2021] [Indexed: 12/24/2022]
Abstract
Background The impact of the coronavirus disease (COVID-19) pandemic on antimicrobial resistance (AMR) is a major concern. Aim To compare the number of patients and isolation rate of antimicrobial-resistant bacteria before and after the beginning of the COVID-19 pandemic using the comprehensive national surveillance data. Methods We utilized comprehensive surveillance data, collected in the Japan Nosocomial Infections Surveillance programme, which included a total of 16.7 million samples of 5.9 million tested patients from >1300 hospitals. We compared the number of patients and isolation rate of five bacteria between 2019 and 2020, including antimicrobial-susceptible and -resistant bacteria of Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Findings The number of patients and isolation rate of S. aureus and meticillin-resistant S. aureus decreased slightly; those of S. pneumoniae and penicillin-resistant S. pneumoniae decreased by 60%; and those of third-generation cephalosporin-resistant K. pneumoniae increased. The isolation rate of the remaining bacteria apparently increased, although the number of patients decreased. This was due to a substantial decrease in the total number of tested patients (the denominator of the isolation rate), which was larger than that of the number of patients (the numerator of the isolation rate). Consistent results were obtained when the same data were re-aggregated using the procedure of the World Health Organization Global Antimicrobial Resistance Surveillance System, demonstrating the general importance of this problem. Conclusion Surveillance data during the COVID-19 pandemic must be carefully interpreted based on examination of the numerator, denominator and background factors that affect the denominator.
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Smith DR, Temime L, Opatowski L. Microbiome-pathogen interactions drive epidemiological dynamics of antibiotic resistance: A modeling study applied to nosocomial pathogen control. eLife 2021; 10:68764. [PMID: 34517942 PMCID: PMC8560094 DOI: 10.7554/elife.68764] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/31/2021] [Indexed: 12/16/2022] Open
Abstract
The human microbiome can protect against colonization with pathogenic antibiotic-resistant bacteria (ARB), but its impacts on the spread of antibiotic resistance are poorly understood. We propose a mathematical modeling framework for ARB epidemiology formalizing within-host ARB-microbiome competition, and impacts of antibiotic consumption on microbiome function. Applied to the healthcare setting, we demonstrate a trade-off whereby antibiotics simultaneously clear bacterial pathogens and increase host susceptibility to their colonization, and compare this framework with a traditional strain-based approach. At the population level, microbiome interactions drive ARB incidence, but not resistance rates, reflecting distinct epidemiological relevance of different forces of competition. Simulating a range of public health interventions (contact precautions, antibiotic stewardship, microbiome recovery therapy) and pathogens (Clostridioides difficile, methicillin-resistant Staphylococcus aureus, multidrug-resistant Enterobacteriaceae) highlights how species-specific within-host ecological interactions drive intervention efficacy. We find limited impact of contact precautions for Enterobacteriaceae prevention, and a promising role for microbiome-targeted interventions to limit ARB spread.
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Affiliation(s)
- David Rm Smith
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France.,Modélisation, épidémiologie et surveillance des risques sanitaires (MESuRS), Conservatoire national des arts et métiers, Paris, France
| | - Laura Temime
- Modélisation, épidémiologie et surveillance des risques sanitaires (MESuRS), Conservatoire national des arts et métiers, Paris, France.,PACRI unit, Institut Pasteur, Conservatoire national des arts et métiers, Paris, France
| | - Lulla Opatowski
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France
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13
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Wyres KL, Hawkey J, Mirčeta M, Judd LM, Wick RR, Gorrie CL, Pratt NF, Garlick JS, Watson KM, Pilcher DV, McGloughlin SA, Abbott IJ, Macesic N, Spelman DW, Jenney AWJ, Holt KE. Genomic surveillance of antimicrobial resistant bacterial colonisation and infection in intensive care patients. BMC Infect Dis 2021; 21:683. [PMID: 34261450 PMCID: PMC8278603 DOI: 10.1186/s12879-021-06386-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Third-generation cephalosporin-resistant Gram-negatives (3GCR-GN) and vancomycin-resistant enterococci (VRE) are common causes of multi-drug resistant healthcare-associated infections, for which gut colonisation is considered a prerequisite. However, there remains a key knowledge gap about colonisation and infection dynamics in high-risk settings such as the intensive care unit (ICU), thus hampering infection prevention efforts. METHODS We performed a three-month prospective genomic survey of infecting and gut-colonising 3GCR-GN and VRE among patients admitted to an Australian ICU. Bacteria were isolated from rectal swabs (n = 287 and n = 103 patients ≤2 and > 2 days from admission, respectively) and diagnostic clinical specimens between Dec 2013 and March 2014. Isolates were subjected to Illumina whole-genome sequencing (n = 127 3GCR-GN, n = 41 VRE). Multi-locus sequence types (STs) and antimicrobial resistance determinants were identified from de novo assemblies. Twenty-three isolates were selected for sequencing on the Oxford Nanopore MinION device to generate completed reference genomes (one for each ST isolated from ≥2 patients). Single nucleotide variants (SNVs) were identified by read mapping and variant calling against these references. RESULTS Among 287 patients screened on admission, 17.4 and 8.4% were colonised by 3GCR-GN and VRE, respectively. Escherichia coli was the most common species (n = 36 episodes, 58.1%) and the most common cause of 3GCR-GN infection. Only two VRE infections were identified. The rate of infection among patients colonised with E. coli was low, but higher than those who were not colonised on admission (n = 2/33, 6% vs n = 4/254, 2%, respectively, p = 0.3). While few patients were colonised with 3GCR- Klebsiella pneumoniae or Pseudomonas aeruginosa on admission (n = 4), all such patients developed infections with the colonising strain. Genomic analyses revealed 10 putative nosocomial transmission clusters (≤20 SNVs for 3GCR-GN, ≤3 SNVs for VRE): four VRE, six 3GCR-GN, with epidemiologically linked clusters accounting for 21 and 6% of episodes, respectively (OR 4.3, p = 0.02). CONCLUSIONS 3GCR-E. coli and VRE were the most common gut colonisers. E. coli was the most common cause of 3GCR-GN infection, but other 3GCR-GN species showed greater risk for infection in colonised patients. Larger studies are warranted to elucidate the relative risks of different colonisers and guide the use of screening in ICU infection control.
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Affiliation(s)
- Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Jane Hawkey
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mirianne Mirčeta
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ryan R Wick
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claire L Gorrie
- Department of Microbiology and Immunology, University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel F Pratt
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jill S Garlick
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Kerrie M Watson
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David V Pilcher
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Steve A McGloughlin
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Iain J Abbott
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nenad Macesic
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Denis W Spelman
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam W J Jenney
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - Kathryn E Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- London School of Hygiene and Tropical Medicine, London, UK
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14
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van Kleef E, Wielders CCH, Schouls LM, Feenstra SG, Hertogh CMPM, Bonten MJM, van Weert Y, Tostmann A, van der Lubben M, de Greeff SC. National point prevalence study on carriage of multidrug-resistant microorganisms in Dutch long-term care facilities in 2018. J Antimicrob Chemother 2021; 76:1604-1613. [PMID: 33694365 DOI: 10.1093/jac/dkab042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/21/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Long-term care facilities (LTCFs) may act as a reservoir of ESBL-producing Enterobacterales (ESBL-E) and carbapenemase-producing Enterobacterales (CPE) for hospitals and the general population. In this study, we estimated the prevalence and molecular epidemiology of rectal carriage with ESBL-E and CPE in residents of Dutch LTCFs between March 2018 and December 2018. METHODS LTCFs were geographically selected across the country. For each LTCF, a random sample of residents were tested for ESBL-E and CPE in 2018. To identify risk factors for high carriage prevalence and/or individual carriage, characteristics of LTCFs and of a subset of the tested residents were collected. WGS was conducted on isolates from LTCFs with an ESBL-E prevalence of >10% and all CPE isolates to identify institutional clonal transmission. RESULTS A total of 4420 residents of 159 LTCFs were included. The weighted mean ESBL-E prevalence was 8.3% (95% CI: 6.8-10.0) and no CPE were found. In 53 LTCFs (33%), where ESBL-E prevalence was >10%, MLST using WGS (wgMLST) was performed. This included 264 isolates, the majority being Escherichia coli (n = 224) followed by Klebsiella pneumoniae (n = 30). Genetic clusters were identified in more than half (30/53; 57%) of high ESBL-positive LTCFs. Among the E. coli isolates, blaCTX-M-15 (92/224; 41%) and blaCTX-M-27 (40/224; 18%) were the most prevalent ESBL-encoding genes. For K. pneumoniae isolates, the most common was blaCTX-M-15 (23/30; 80%). CONCLUSIONS The estimated prevalence of ESBL-E rectal carriage in Dutch LTCFs is 8.3% and resistance is observed mainly in E. coli with predominance of blaCTX-M-15 and blaCTX-M-27. ESBL-E prevalence in LTCFs seems comparable to previously reported prevalence in hospitals and the general population.
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Affiliation(s)
- Esther van Kleef
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium.,Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM) Bilthoven, The Netherlands
| | - Cornelia C H Wielders
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM) Bilthoven, The Netherlands
| | - Leo M Schouls
- Centre for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM) Bilthoven, The Netherlands
| | - Sabiena G Feenstra
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM) Bilthoven, The Netherlands
| | - Cees M P M Hertogh
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM) Bilthoven, The Netherlands.,Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam Medical Centers, Amsterdam, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Yolanda van Weert
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM) Bilthoven, The Netherlands
| | - Alma Tostmann
- Hygiene and Infection Prevention Unit, Department of Medical Microbiology, Radboud Centre for Infectious Diseases, Radboud university medical centre, Nijmegen, The Netherlands.,Regional Epidemiology Consultant, Gelderland AMR and Infection Prevention Network, The Netherlands
| | - Mariken van der Lubben
- Regional laboratory, Municipal Health Service (GGD) Amsterdam, Amsterdam, The Netherlands
| | - Sabine C de Greeff
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM) Bilthoven, The Netherlands
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15
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Brilhante M, Gobeli Brawand S, Endimiani A, Rohrbach H, Kittl S, Willi B, Schuller S, Perreten V. Two high-risk clones of carbapenemase-producing Klebsiella pneumoniae that cause infections in pets and are present in the environment of a veterinary referral hospital. J Antimicrob Chemother 2021; 76:1140-1149. [PMID: 33615354 DOI: 10.1093/jac/dkab028] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/20/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Infections with carbapenem-resistant Enterobacterales (CRE) are an emerging problem in pets and a major threat to public health. We determined the genetic relationships among carbapenemase-producing Klebsiella pneumoniae (CPKp) strains causing infections in hospitalized pets in a veterinary clinic and those found in the environment. METHODS WGS was performed with both the Illumina and Nanopore platforms. Searches of genetic features were performed using several databases and bioinformatics tools, and phylogeny was assessed by whole-genome MLST (wgMLST) using SeqSphere and SNP calling with Snippy. RESULTS WGS analysis of the CPKp strains identified all environmental and almost all animal strains as the high-risk clone ST11, with the exception of two strains that belonged to ST307. All CPKp belonged to novel complex types (CTs) and carried a conjugative 63 kb IncL plasmid encoding the carbapenemase gene blaOXA-48, yersiniabactin and other virulence factors. Although all CPKp ST11 strains carried additional similar IncR plasmids harbouring multiple antimicrobial resistance genes (ARGs), such as the plasmid-mediated blaDHA-1 AmpC gene, some structural variations were observed. The two ST307 strains carried identical 156 kb MDR IncFIB(K) plasmids with several ARGs, including the blaCTX-M-15 ESBL gene. Both wgMLST and cgSNP analysis confirmed that CPKp strains of the same ST were genetically highly related independent of the source of isolation. CONCLUSIONS This study demonstrated that the clinical CPKp strains were highly related to those contaminating the clinical environment. These findings confirmed nosocomial spread and highlight veterinary hospitals as a source of CPKp, which may further spread to animals, the environment and humans.
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Affiliation(s)
- Michael Brilhante
- Institute of Veterinary Bacteriology, University of Bern, Bern, Switzerland.,Graduate School of Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | | | - Andrea Endimiani
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Helene Rohrbach
- Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland
| | - Sonja Kittl
- Institute of Veterinary Bacteriology, University of Bern, Bern, Switzerland
| | - Barbara Willi
- Clinic for Small Animal Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Simone Schuller
- Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland
| | - Vincent Perreten
- Institute of Veterinary Bacteriology, University of Bern, Bern, Switzerland
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16
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Relevance of intra-hospital patient movements for the spread of healthcare-associated infections within hospitals - a mathematical modeling study. PLoS Comput Biol 2021; 17:e1008600. [PMID: 33534784 PMCID: PMC7857595 DOI: 10.1371/journal.pcbi.1008600] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/02/2020] [Indexed: 11/23/2022] Open
Abstract
The aim of this study is to analyze patient movement patterns between hospital departments to derive the underlying intra-hospital movement network, and to assess if movement patterns differ between patients at high or low risk of colonization. For that purpose, we analyzed patient electronic medical record data from five hospitals to extract information on risk stratification and patient intra-hospital movements. Movement patterns were visualized as networks, and network centrality measures were calculated. Next, using an agent-based model where agents represent patients and intra-hospital patient movements were explicitly modeled, we simulated the spread of multidrug resistant enterobacteriacae (MDR-E) inside a hospital. Risk stratification of patients according to certain ICD-10 codes revealed that length of stay, patient age, and mean number of movements per admission were higher in the high-risk groups. Movement networks in all hospitals displayed a high variability among departments concerning their network centrality and connectedness with a few highly connected departments and many weakly connected peripheral departments. Simulating the spread of a pathogen in one hospital network showed positive correlation between department prevalence and network centrality measures. This study highlights the importance of intra-hospital patient movements and their possible impact on pathogen spread. Targeting interventions to departments of higher (weighted) degree may help to control the spread of MDR-E. Moreover, when the colonization status of patients coming from different departments is unknown, a ranking system based on department centralities may be used to design more effective interventions that mitigate pathogen spread. Pathogens including multidrug resistant enterobacteriacae (MDR-E) inside hospital settings are associated with higher morbidity, mortality, and healthcare costs. Better understanding of the transmission routes of these pathogens is required to develop targeted and efficient measures to contain the spread of MDR-E in a hospital. We analyzed datasets from five hospitals in different countries to explore patient movement patterns between departments of these hospitals (intra-hospital movements). We assessed whether movement patterns differ between patients at high or low risk of colonization. Our results show that in every intra-hospital network, there exist a few departments which are strongly connected and many peripheral departments which are loosely connected. High-risk patients stay on average longer in the hospital, and move more frequently between departments than low-risk patients. Targeting interventions to strongly connected departments may help to reduce pathogen spread inside the hospital. To explore this, we simulated the spread of MDR-E inside one hospital using an agent-based model that includes patient movements. In the simulations, we found positive correlations between departments’ prevalence and network characteristics such as degree and weighted degree, thus highlighting the importance of targeting interventions to departments of higher (weighted) degree to control the spread of MDR-E.
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17
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Getanda P, Bojang A, Camara B, Jagne-Cox I, Usuf E, Howden BP, D'Alessandro U, Bottomley C, Roca A. Short-term increase in the carriage of azithromycin-resistant Escherichia coli and Klebsiella pneumoniae in mothers and their newborns following intra-partum azithromycin: a post hoc analysis of a double-blind randomized trial. JAC Antimicrob Resist 2021; 3:dlaa128. [PMID: 34223077 PMCID: PMC8210243 DOI: 10.1093/jacamr/dlaa128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/17/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives To evaluate the impact of one oral dose of intrapartum azithromycin (2 g) on the carriage and antibiotic resistance of Escherichia coli and Klebsiella pneumoniae in the nasopharynx, breast milk and vaginal swabs of mothers and K. pneumoniae in the nasopharynx of their newborns. Methods We performed a post hoc analysis of a double-blind, placebo-controlled randomized-trial (ratio 1:1) conducted in The Gambia. Breast milk (BM) and vaginal swabs (VS) from mothers and nasopharyngeal swabs (NPS) from mother-newborn pairs were collected at different timepoints during the 4 week follow-up. Samples were processed using standard microbiological procedures. For BM and NPS post-intervention results were combined for analysis. Results In the original trial 829 mothers were randomized. In this analysis, complete sample sets were available for 630 mothers for E. coli analysis (76.0%) and 564 mother-newborn pairs for K. pneumoniae analysis (68.0%). For E. coli, carriage prevalence in BM and VS was similar in both arms but resistance was higher in the azithromycin arm in VS (2.6% versus 0%, P = 0.004). For K. pneumoniae, carriage prevalence was higher in the azithromycin arm for BM (13.8% versus 8.7%, P = 0.055) but not for VS or NPS. Prevalence of azithromycin resistant K. pneumoniae was higher in the azithromycin arm for BM (3.6% versus 1.0%, P = 0.050) and VS (1.5% versus 0% P = 0.057). Conclusions Oral intrapartum azithromycin did not reduce carriage of E. coli and K. pneumoniae and was associated with an increase in the prevalence of azithromycin-resistant E. coli and K. pneumoniae isolates in BM and VS.
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Affiliation(s)
- Pauline Getanda
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Abdoulie Bojang
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Bully Camara
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Isatou Jagne-Cox
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Effua Usuf
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Benjamin P Howden
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, University of Melbourne, Doherty Institute for Infection and Immunity, Victoria, Australia
| | - Umberto D'Alessandro
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Christian Bottomley
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Roca
- Disease Control and Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
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18
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Cost-effectiveness analysis of whole-genome sequencing during an outbreak of carbapenem-resistant Acinetobacter baumannii. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e62. [PMID: 36168472 PMCID: PMC9495627 DOI: 10.1017/ash.2021.233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 11/12/2022]
Abstract
Background: Whole-genome sequencing (WGS) shotgun metagenomics (metagenomics) attempts to sequence the entire genetic content straight from the sample. Diagnostic advantages lie in the ability to detect unsuspected, uncultivatable, or very slow-growing organisms. Objective: To evaluate the clinical and economic effects of using WGS and metagenomics for outbreak management in a large metropolitan hospital. Design: Cost-effectiveness study. Setting: Intensive care unit and burn unit of large metropolitan hospital. Patients: Simulated intensive care unit and burn unit patients. Methods: We built a complex simulation model to estimate pathogen transmission, associated hospital costs, and quality-adjusted life years (QALYs) during a 32-month outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB). Model parameters were determined using microbiology surveillance data, genome sequencing results, hospital admission databases, and local clinical knowledge. The model was calibrated to the actual pathogen spread within the intensive care unit and burn unit (scenario 1) and compared with early use of WGS (scenario 2) and early use of WGS and metagenomics (scenario 3) to determine their respective cost-effectiveness. Sensitivity analyses were performed to address model uncertainty. Results: On average compared with scenario 1, scenario 2 resulted in 14 fewer patients with CRAB, 59 additional QALYs, and $75,099 cost savings. Scenario 3, compared with scenario 1, resulted in 18 fewer patients with CRAB, 74 additional QALYs, and $93,822 in hospital cost savings. The likelihoods that scenario 2 and scenario 3 were cost-effective were 57% and 60%, respectively. Conclusions: The use of WGS and metagenomics in infection control processes were predicted to produce favorable economic and clinical outcomes.
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Modelling pathogen spread in a healthcare network: Indirect patient movements. PLoS Comput Biol 2020; 16:e1008442. [PMID: 33253154 PMCID: PMC7728397 DOI: 10.1371/journal.pcbi.1008442] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 12/10/2020] [Accepted: 10/16/2020] [Indexed: 11/28/2022] Open
Abstract
Inter-hospital patient transfers (direct transfers) between healthcare facilities have been shown to contribute to the spread of pathogens in a healthcare network. However, the impact of indirect transfers (patients re-admitted from the community to the same or different hospital) is not well studied. This work aims to study the contribution of indirect transfers to the spread of pathogens in a healthcare network. To address this aim, a hybrid network–deterministic model to simulate the spread of multiresistant pathogens in a healthcare system was developed for the region of Lower Saxony (Germany). The model accounts for both, direct and indirect transfers of patients. Intra-hospital pathogen transmission is governed by a SIS model expressed by a system of ordinary differential equations. Our results show that the proposed model reproduces the basic properties of healthcare-associated pathogen spread. They also show the importance of indirect transfers: restricting the pathogen spread to direct transfers only leads to 4.2% system wide prevalence. However, adding indirect transfers leads to an increase in the overall prevalence by a factor of 4 (18%). In addition, we demonstrated that the final prevalence in the individual healthcare facilities depends on average length of stay in a way described by a non-linear concave function. Moreover, we demonstrate that the network parameters of the model may be derived from administrative admission/discharge records. In particular, they are sufficient to obtain inter-hospital transfer probabilities, and to express the patients’ transfers as a Markov process. Using the proposed model, we show that indirect transfers of patients are equally or even more important as direct transfers for the spread of pathogens in a healthcare network. Direct patient transfers between hospitals have been shown to play an important role in the spread of pathogens in a healthcare network. However, readmission of patients from the community (indirect transfers) to the same or a different hospital is not well studied, and its role for the spread of pathogens in a healthcare network is not quantified. In this work, we developed a network model of a healthcare system to study the impact of indirect transfers on the prevalence in the individual hospitals as well as in the overall healthcare system. The model includes both, direct and indirect transfers of patients between the healthcare facilities due to transferring as well as readmission of infectious (colonized or infected) patients. Our results show that the readmission of patients (indirect transfers), either to the same or different facility, is an important potential channel of pathogen transmission. Such indirect transfers are of no less importance than direct patient transfers in controlling the spread of pathogens in a healthcare network.
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Souza SGPD, Santos ICD, Bondezan MAD, Corsatto LFM, Caetano ICDS, Zaniolo MM, Matta RD, Merlini LS, Barbosa LN, Gonçalves DD. Bacteria with a Potential for Multidrug Resistance in Hospital Material. Microb Drug Resist 2020; 27:835-842. [PMID: 33232623 DOI: 10.1089/mdr.2019.0305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective of this research was to determine the antimicrobial resistance of bacteria isolated from items related to hygiene and antisepsis, equipment, and instruments used in different hospital wards. Bacterial isolation and identification, phenotypic antimicrobial susceptibility assays, mecA gene detection, and multiple antimicrobial resistance index analysis were performed. In total, 105 bacteria were isolated from 138 items. Of these, 49.52% bacteria were collected from instruments, 43.80% from equipment, and 6.66% from items related to hygiene and antisepsis. All gram-positive bacteria (88 isolates) were identified as coagulase-negative Staphylococcus. Five species of gram-negative bacilli (17 isolates) were isolated, and the prevalence of Enterobacter agglomerans (29.41%), Escherichia coli (11.76%), and Serratia liquefaciens (11.76%) was high. Antimicrobial resistance was reported for 93.33% of the isolates. Gram-positive bacteria were resistant to sulfazotrim (88.64%) and penicillin (82.95%), while gram-negative bacteria showed resistance to sulfazotrim (70.59%) and ampicillin (64.71%). Analysis of multiple antibiotic resistance index showed that 73.33% of the isolates were a high risk to public health. The mecA gene was detected in 23 (71.88%) isolates. The evaluation of microorganisms isolated in the hospital environment revealed their high multidrug resistance index. Thus our study presses the need to pay more attention to the cleanliness of frequently used instruments, which may be potential sources of infections.
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Affiliation(s)
- Sandra Geane Pereira de Souza
- Programa de Pós-Graduação em Ciência Animal com Ênfase em Produtos Bioativos, Universidade Paranaense (UNIPAR), Umuarama, Brazil
| | - Isabela Carvalho Dos Santos
- Programa de Pós-Graduação em Ciência Animal com Ênfase em Produtos Bioativos, Universidade Paranaense (UNIPAR), Umuarama, Brazil
| | | | | | - Isabel Cristina da Silva Caetano
- Programa de Pós-Graduação em Ciência Animal com Ênfase em Produtos Bioativos, Universidade Paranaense (UNIPAR), Umuarama, Brazil
| | - Melissa Marchi Zaniolo
- Programa de Pós-Graduação em Ciência Animal com Ênfase em Produtos Bioativos, Universidade Paranaense (UNIPAR), Umuarama, Brazil
| | - Rosana da Matta
- Mestre Profissional em Plantas Medicinais e Fitoterápicos na Atenção Básica, Universidade Paranaense (UNIPAR), Umuarama, Brazil
| | - Luiz Sérgio Merlini
- Programa de Pós-Graduação em Ciência Animal com Ênfase em Produtos Bioativos, Universidade Paranaense (UNIPAR), Umuarama, Brazil
| | - Lidiane Nunes Barbosa
- Programa de Pós-Graduação em Ciência Animal com Ênfase em Produtos Bioativos, Universidade Paranaense (UNIPAR), Umuarama, Brazil
| | - Daniela Dib Gonçalves
- Programa de Pós-Graduação em Ciência Animal com Ênfase em Produtos Bioativos, Universidade Paranaense (UNIPAR), Umuarama, Brazil
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Assawatheptawee K, Kiddee A, Na-Udom A, Wangteeraprasert A, Treebupachatsakul P, Niumsup PR. Acquisition of extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae in intensive care units in Thailand. J Infect Chemother 2020; 27:401-405. [PMID: 33132043 DOI: 10.1016/j.jiac.2020.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 09/27/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022]
Abstract
This study aimed to assess the prevalence and associated risk factors for extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EK) acquisition among patients staying in medical and surgical Intensive Care Units (ICU) in Northern Thailand. Rectal swabs were collected from 206 ICU patients upon admission and discharge. Overall, the ESBL-EK acquisition rate among patients during ICU stay was 29.6%. Acquisition rate was significantly higher for K. pneumoniae (20.9%) than that of E. coli (12.1%) (p = 0.024). Multivariate logistic regression analysis identified the use of third generation cephalosporin (p = 0.008) as a risk factor for ESBL-EK acquisition. Sixty-eight ESBL-EK isolates (25 E. coli and 43 K. pneumoniae) were recovered. The majority of ESBL-EK isolates (≥88%) were resistant to ceftazidime, cefepime and aztreonam. Fifty-two acquired ESBL-EK isolates (76.5%) were positive for blaCTX-M and 4 K. pneumoniae isolates simultaneously carried blaNDM-1. Our results reveal that ICU patients could acquire ESBL-EK during hospitalization and the use of third generation cephalosporin should be strictly controlled to prevent the acquisition of ESBL-EK among ICU patients.
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Affiliation(s)
- Kanit Assawatheptawee
- Department of Microbiology and Parasitology, Faculty of Medical Science, Naresuan University, Phitsanulok, 65000, Thailand
| | - Anong Kiddee
- Department of Microbiology and Parasitology, Faculty of Medical Science, Naresuan University, Phitsanulok, 65000, Thailand
| | - Anamai Na-Udom
- Department of Mathematics, Faculty of Science, Naresuan University, Phitsanulok, 65000, Thailand
| | | | | | - Pannika R Niumsup
- Department of Microbiology and Parasitology, Faculty of Medical Science, Naresuan University, Phitsanulok, 65000, Thailand.
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22
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Piotrowska MJ, Sakowski K, Lonc A, Tahir H, Kretzschmar ME. Impact of inter-hospital transfers on the prevalence of resistant pathogens in a hospital-community system. Epidemics 2020; 33:100408. [PMID: 33128935 DOI: 10.1016/j.epidem.2020.100408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/21/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022] Open
Abstract
The spread of resistant bacteria in hospitals is an increasing problem worldwide. Transfers of patients, who may be colonized with resistant bacteria, are considered to be an important driver of promoting resistance. Even though transmission rates within a hospital are often low, readmissions of patients who were colonized during an earlier hospital stay lead to repeated introductions of resistant bacteria into hospitals. We developed a mathematical model that combines a deterministic model for within-hospital spread of pathogens, discharge to the community and readmission, with a hospital-community network simulation of patient transfers between hospitals. Model parameters used to create the hospital-community network are obtained from two health insurance datasets from Germany. For parameter values representing transmission of resistant Enterobacteriaceae, we compute estimates for the single admission reproduction numbers RA and the basic reproduction numbers R0 per hospital-community pair. We simulate the spread of colonization through the network of hospitals, and investigate how increasing connectedness of hospitals through the network influences the prevalence in the hospital-community pairs. We find that the prevalence in hospitals is determined by their RA and R0 values. Increasing transfer rates between network nodes tend to lower the overall prevalence in the network by diluting the high prevalence of hospitals with high R0 to hospitals where persistent spread is not possible. We conclude that hospitals with high reproduction numbers represent a continuous source of risk for importing resistant pathogens for hospitals with otherwise low levels of transmission. Moreover, high risk hospital-community nodes act as reservoirs of pathogens in a densely connected network.
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Affiliation(s)
- M J Piotrowska
- Institute of Applied Mathematics and Mechanics, University of Warsaw, Banacha 2, 02-097 Warsaw, Poland
| | - K Sakowski
- Institute of Applied Mathematics and Mechanics, University of Warsaw, Banacha 2, 02-097 Warsaw, Poland; Institute of High Pressure Physics, Polish Academy of Sciences, Sokolowska 29/37, 01-142 Warsaw, Poland; Research Institute for Applied Mechanics, Kyushu University, Kasuga, Fukuoka 816-8580, Japan.
| | - A Lonc
- Institute of Applied Mathematics and Mechanics, University of Warsaw, Banacha 2, 02-097 Warsaw, Poland
| | - H Tahir
- Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - M E Kretzschmar
- Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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23
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Iroh Tam PY, Musicha P, Kawaza K, Cornick J, Denis B, Freyne B, Everett D, Dube Q, French N, Feasey N, Heyderman R. Emerging Resistance to Empiric Antimicrobial Regimens for Pediatric Bloodstream Infections in Malawi (1998-2017). Clin Infect Dis 2020; 69:61-68. [PMID: 30277505 PMCID: PMC6579959 DOI: 10.1093/cid/ciy834] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/28/2018] [Indexed: 11/14/2022] Open
Abstract
Background The adequacy of the World Health Organization’s Integrated Management of Childhood Illness (IMCI) antimicrobial guidelines for the treatment of suspected severe bacterial infections is dependent on a low prevalence of antimicrobial resistance (AMR). We describe trends in etiologies and susceptibility patterns of bloodstream infections (BSI) in hospitalized children in Malawi. Methods We determined the change in the population-based incidence of BSI in children admitted to Queen Elizabeth Central Hospital, Blantyre, Malawi (1998–2017). AMR profiles were assessed by the disc diffusion method, and trends over time were evaluated. Results A total 89643 pediatric blood cultures were performed, and 10621 pathogens were included in the analysis. Estimated minimum incidence rates of BSI for those ≤5 years of age fell from a peak of 11.4 per 1000 persons in 2002 to 3.4 per 1000 persons in 2017. Over 2 decades, the resistance of Gram-negative pathogens to all empiric, first-line antimicrobials (ampicillin/penicillin, gentamicin, ceftriaxone) among children ≤5 years increased from 3.4% to 30.2% (P < .001). Among those ≤60 days, AMR to all first-line antimicrobials increased from 7.0% to 67.7% (P < .001). Among children ≤5 years, Klebsiella spp. resistance to all first-line antimicrobial regimens increased from 5.9% to 93.7% (P < .001). Conclusions The incidence of BSI among hospitalized children has decreased substantially over the last 20 years, although gains have been offset by increases in Gram-negative pathogens’ resistance to all empiric first-line antimicrobials. There is an urgent need to address the broader challenge of adapting IMCI guidelines to the local setting in the face of rapidly-expanding AMR in childhood BSI.
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Affiliation(s)
- Pui-Ying Iroh Tam
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, United Kingdom
| | - Patrick Musicha
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, United Kingdom
| | | | - Jenifer Cornick
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Brigitte Denis
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Dean Everett
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,The Queens Medical Research Institute, University of Edinburgh, United Kingdom
| | - Queen Dube
- University of Malawi College of Medicine, Blantyre
| | - Neil French
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Institute of Infection and Global Health, University of Liverpool, United Kingdom
| | - Nicholas Feasey
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, United Kingdom
| | - Robert Heyderman
- Malawi-Liverpool Wellcome Trust, Institute of Infection and Global Health, University of Liverpool, United Kingdom.,University College London, United Kingdom
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24
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Lee XJ, Elliott TM, Harris PNA, Douglas J, Henderson B, Watson C, Paterson DL, Schofield DS, Graves N, Gordon LG. Clinical and Economic Outcomes of Genome Sequencing Availability on Containing a Hospital Outbreak of Resistant Escherichia coli in Australia. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:994-1002. [PMID: 32828227 DOI: 10.1016/j.jval.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/12/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To evaluate the outbreak size and hospital cost effects of bacterial whole-genome sequencing availability in managing a large-scale hospital outbreak. METHODS We built a hybrid discrete event/agent-based simulation model to replicate a serious bacterial outbreak of resistant Escherichia coli in a large metropolitan public hospital during 2017. We tested the 3 strategies of using whole-genome sequencing early, late (actual outbreak), or not using it and assessed their associated outbreak size and hospital cost. The model included ward dynamics, pathogen transmission, and associated hospital costs during a 5-month outbreak. Model parameters were determined using data from the Queensland Hospital Admitted Patient Data Collection (N = 4809 patient admissions) and local clinical knowledge. Sensitivity analyses were performed to address model and parameter uncertainty. RESULTS An estimated 197 patients were colonized during the outbreak, with 75 patients detected. The total outbreak cost was A$460 137 (US$317 117), with 6.1% spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients, costing A$766 921 (US$528 547). With earlier detection from use of routine sequencing, the estimated outbreak size was 3 patients and cost A$65 374 (US$45 054). CONCLUSIONS Using whole-genome sequencing in hospital outbreak management was associated with smaller outbreaks and cost savings, with sequencing costs as a small fraction of total hospital costs, supporting the further investigation of the use of routine whole-genome sequencing in hospitals.
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Affiliation(s)
- Xing J Lee
- Queensland University of Technology (QUT), Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovations, Kelvin Grove, Queensland, Australia
| | - Thomas M Elliott
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Patrick N A Harris
- Queensland Health, Pathology Queensland, Herston, Queensland, Australia; University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
| | - Joel Douglas
- Queensland Health, Pathology Queensland, Herston, Queensland, Australia
| | - Belinda Henderson
- Infection Management Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Catherine Watson
- Infection Management Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
| | | | - Nicholas Graves
- Queensland University of Technology (QUT), Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovations, Kelvin Grove, Queensland, Australia
| | - Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia; Queensland Health, Pathology Queensland, Herston, Queensland, Australia; Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Queensland, Australia; School of Public Health, The University of Queensland, Herston, Queensland, Australia.
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25
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Zahar JR, Blot S, Nordmann P, Martischang R, Timsit JF, Harbarth S, Barbier F. Screening for Intestinal Carriage of Extended-spectrum Beta-lactamase-producing Enterobacteriaceae in Critically Ill Patients: Expected Benefits and Evidence-based Controversies. Clin Infect Dis 2020; 68:2125-2130. [PMID: 30312366 DOI: 10.1093/cid/ciy864] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022] Open
Abstract
The rising burden of intensive care unit (ICU)-acquired infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) strengthens the requirement for efficient prevention strategies. The detection of intestinal carriage of ESBL-E through active surveillance cultures (ASC) and the implementation of contact precautions (CP) in carriers are currently advocated in most high-income countries, to prevent cross-transmission and subsequent ESBL-E infections in critically-ill patients. Yet, recent studies have challenged the benefit of ASC and CP in controlling the spread of ESBL-E in ICUs with high compliance to standard hygiene precautions and no ongoing outbreak of ESBL-producing Klebsiella pneumoniae or Enterobacter spp. Besides, given their debated performance to positively predict which patients are at risk of ESBL-E infections, ASC results appear of limited value to rationalize the empirical use of carbapenems in the ICU, emphasizing the urgent need for novel anticipatory and diagnostic approaches. This Viewpoint article summarizes the available evidence on these issues.
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Affiliation(s)
- Jean-Ralph Zahar
- Infection Control Unit, Avicenne University Hospital, Assistance Publique - Hôpitaux de Paris, Bobigny.,INSERM, Infection Antimicrobial Modelling Evolution, UMR 1137, Paris Diderot, Sorbonne Paris Cité University, France
| | - Stijn Blot
- Department of Internal Medicine, Ghent University, Belgium.,Burns, Trauma and Critical Care Research Centre, Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Patrice Nordmann
- Medical and Molecular Microbiology Unit, Department of Medicine, Faculty of Science, INSERM European Unit.,Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg.,Institute for Microbiology, University of Lausanne and University Hospital Centre
| | - Romain Martischang
- Infection Control Program and World Health Organization Collaborating Center, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Jean-François Timsit
- INSERM, Infection Antimicrobial Modelling Evolution, UMR 1137, Paris Diderot, Sorbonne Paris Cité University, France.,Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, APHP, Paris
| | - Stephan Harbarth
- Infection Control Program and World Health Organization Collaborating Center, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, Orléans, France
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26
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Abstract
PURPOSE OF REVIEW Antimicrobial resistance (AMR) is increasing in ICUs around the world, but the prevalence is variable. We will review recent literature and try to answer the question whether this is a myth or a new reality, as well as discuss challenges and potential solutions. RECENT FINDINGS AMR is diverse, and currently Gram-negative multidrug-resistant organisms (MDROs) are the main challenge in ICUs worldwide. Geographical variation in prevalence of MDROs is substantial, and local epidemiology should be considered to assess the current threat of AMR. ICU patients are at a high risk of infection with MDRO because often multiple risk factors are present. Solutions should focus on reducing the risk of cross-transmission in the ICU through strict infection prevention and control practices and reducing exposure to antimicrobials as the major contributor to the development of AMR. SUMMARY AMR is a reality in most ICUs around the world, but the extent of the problem is clearly highly variable. Infection prevention and control as well as appropriate antimicrobial use are the cornerstones to turn the tide.
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27
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Jolivet S, Lolom I, Bailly S, Bouadma L, Lortat-Jacob B, Montravers P, Armand-Lefevre L, Timsit JF, Lucet JC. Impact of colonization pressure on acquisition of extended-spectrum β-lactamase-producing Enterobacterales and meticillin-resistant Staphylococcus aureus in two intensive care units: a 19-year retrospective surveillance. J Hosp Infect 2020; 105:10-16. [PMID: 32092367 DOI: 10.1016/j.jhin.2020.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonization pressure is a risk factor for intensive care unit (ICU)-acquired multi-drug-resistant organisms (MDROs). AIM To measure the long-term respective impact of colonization pressure on ICU-acquired extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) and meticillin-resistant Staphylococcus aureus (MRSA). METHODS All patients admitted to two ICUs (medical and surgical) between January 1997 and December 2015 were included in this retrospective observational study. Rectal and nasal surveillance cultures were obtained at admission and weekly thereafter. Contact precautions were applied for colonized or infected patients. Colonization pressure was defined as the ratio of the number of MDRO-positive patient-days (PDs) of each MDRO to the total number of PDs. Single-level negative binomial regression models were used to evaluate the incidence of weekly MDRO acquisition. FINDINGS Among the 23,423 patients included, 2327 (10.0%) and 1422 (6.1%) were colonized with ESBL-PE and MRSA, respectively, including 660 (2.8%) and 351 (1.5%) acquisitions. ESBL-PE acquisition increased from 0.51/1000 patient-exposed days (PEDs) in 1997 to 6.06/1000 PEDs in 2015 (P<0.001). In contrast, MRSA acquisition decreased steadily from 3.75 to 0.08/1000 PEDs (P<0.001). Controlling for period-level covariates, colonization pressure in the previous week was associated with MDRO acquisition for ESBL-PE (P<0.001 and P=0.04 for medical and surgical ICU, respectively), but not for MRSA (P=0.34 and P=0.37 for medical and surgical ICU, respectively). The increase in colonization pressure was significant above 100/1000 PDs for ESBL-PE. CONCLUSION Colonization pressure contributed to the increasing incidence of ESBL-PE but not MRSA. This study suggests that preventive control measures should be customized to MDROs.
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Affiliation(s)
- S Jolivet
- Infection Control Unit, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; IAME, UMR 1137, INSERM, Université de Paris, Paris, France.
| | - I Lolom
- Infection Control Unit, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - S Bailly
- University Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, Grenoble, France
| | - L Bouadma
- IAME, UMR 1137, INSERM, Université de Paris, Paris, France; Medical Intensive Care Unit, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - B Lortat-Jacob
- Department of Anaesthesiology and Intensive Care, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - P Montravers
- Department of Anaesthesiology and Intensive Care, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM UMR 1152, Paris, France
| | - L Armand-Lefevre
- IAME, UMR 1137, INSERM, Université de Paris, Paris, France; Bacteriology Laboratory, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - J-F Timsit
- IAME, UMR 1137, INSERM, Université de Paris, Paris, France; Medical Intensive Care Unit, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - J-C Lucet
- Infection Control Unit, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; IAME, UMR 1137, INSERM, Université de Paris, Paris, France
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28
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Contact isolation versus standard precautions to decrease acquisition of extended-spectrum β-lactamase-producing Enterobacterales in non-critical care wards: a cluster-randomised crossover trial. THE LANCET. INFECTIOUS DISEASES 2020; 20:575-584. [PMID: 32087113 DOI: 10.1016/s1473-3099(19)30626-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 09/02/2019] [Accepted: 10/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The effectiveness of contact isolation for decreasing the spread of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) has been questioned. The aim of this study was to establish the benefits of contact isolation over standard precautions for reducing the incidence density of ESBL-E colonisation and infection in adult medical and surgical wards with an active surveillance culture programme. METHODS We did a cluster-randomised crossover trial in adult wards in four European university hospitals. Medical, surgical, or combined medical-surgical wards without critical care were randomised to continue standard precautions alone or implement contact isolation alongside standard precautions for 12 months, followed by a 1 month washout period and 12 months of the alternate strategy. Randomisation was done via a computer-generated sequence, with a block size of two consecutive wards. Only laboratory technicians and data analysts were masked to allocation. Patients were screened for ESBL-E carriage within 3 days of admission, once a week thereafter, and on discharge. The primary outcome was the incidence density of ESBL-E, defined as the acquisition rate per 1000 patient-days at risk at the ward level and assessed in the per-protocol population, which included all patients screened at least twice with a length of stay of more than 1 week for each intervention period. No specific safety measures were assessed given the minimal risk of adverse events. The trial is registered, ISRCTN57648070. FINDINGS We enrolled 20 wards from four hospitals in Germany (eight wards), the Netherlands (four wards), Spain (four wards), and Switzerland (four wards). Between Jan 6, 2014, and Aug 31, 2016, 38 357 patients were admitted to these wards. Among 15 184 patients with a length of stay of more than 1 week, 11 368 patients (75%) were screened at least twice. The incidence density of ward-acquired ESBL-E was 6·0 events per 1000 patient-days at risk (95% CI 5·4-6·7) during periods of contact isolation and 6·1 (5·5-6·7) during periods of standard precautions (p=0·9710). Multivariable analysis adjusted for length of stay, percentage of patients screened, and prevalence in first screening cultures yielded an incidence rate ratio of 0·99 (95% CI 0·80-1·22; p=0·9177) for care under contact isolation compared with standard precautions. INTERPRETATION Contact isolation showed no benefit when added to standard precautions for controlling the spread of ESBL-E on non-critical care wards with extensive surveillance screening. FUNDING European Commission.
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29
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Biehl LM, Vehreschild MJGT. Contact precautions: no benefits, no indication. THE LANCET. INFECTIOUS DISEASES 2020; 20:516-517. [PMID: 32087117 DOI: 10.1016/s1473-3099(20)30017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Lena M Biehl
- Department I of Internal Medicine, Faculty of Medicine; and University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany.
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Faculty of Medicine; and University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
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30
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Elliott TM, Lee XJ, Foeglein A, Harris PN, Gordon LG. A hybrid simulation model approach to examine bacterial genome sequencing during a hospital outbreak. BMC Infect Dis 2020; 20:72. [PMID: 31973703 PMCID: PMC6979342 DOI: 10.1186/s12879-019-4743-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/27/2019] [Indexed: 12/21/2022] Open
Abstract
Background Hospital infection control requires timely detection and identification of organisms, and their antimicrobial susceptibility. We describe a hybrid modeling approach to evaluate whole genome sequencing of pathogens for improving clinical decisions during a 2017 hospital outbreak of OXA-181 carbapenemase-producing Escherichia coli and the associated economic effects. Methods Combining agent-based and discrete-event paradigms, we built a hybrid simulation model to assess hospital ward dynamics, pathogen transmission and colonizations. The model was calibrated to exactly replicate the real-life outcomes of the outbreak at the ward-level. Seven scenarios were assessed including genome sequencing (early or late) and no sequencing (usual care). Model inputs included extent of microbiology and sequencing tests, patient-level data on length of stay, hospital ward movement, cost data and local clinical knowledge. The main outcomes were outbreak size and hospital costs. Model validation and sensitivity analyses were performed to address uncertainty around data inputs and calibration. Results An estimated 197 patients were colonized during the outbreak with 75 patients detected. The total outbreak cost was US$318,654 with 6.1% of total costs spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients costing US$531,109. Microbiology tests were the largest cost component across all scenarios. Conclusion A hybrid simulation approach using the advantages of both agent-based and discrete-event modeling successfully replicated a real-life bacterial hospital outbreak as a foundation for evaluating clinical outcomes and efficiency of outbreak management. Whole genome sequencing of a potentially serious pathogen appears effective in containing an outbreak and minimizing hospital costs.
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Affiliation(s)
- Thomas M Elliott
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, Q4006, Australia.
| | - Xing J Lee
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, 4059, Australia
| | - Anna Foeglein
- Heisenberg Analytics, Indooroopilly, QLD, 4068, Australia
| | - Patrick N Harris
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD, Australia
| | - Louisa G Gordon
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, Q4006, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia.,School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Q4059, Australia
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31
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Bonneault M, Andrianoelina VH, Herindrainy P, Rabenandrasana MAN, Garin B, Breurec S, Delarocque-Astagneau E, Guillemot D, Andrianirina ZZ, Collard JM, Huynh BT, Opatowski L. Transmission Routes of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae in a Neonatology Ward in Madagascar. Am J Trop Med Hyg 2020; 100:1355-1362. [PMID: 31017082 DOI: 10.4269/ajtmh.18-0410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The diffusion of extended-spectrum beta-lactamase (E-ESBL)-producing Enterobacteriaceae is a major concern worldwide, especially in low-income countries, where they may lead to therapeutic failures. In hospitals, where colonization is the highest, E-ESBL transmission is poorly understood, limiting the possibility of establishing effective control measures. We assessed E-ESBL-acquisition routes in a neonatalogy ward in Madagascar. Individuals from a neonatology ward were longitudinally followed-up (August 2014-March 2015). Newborns' family members' and health-care workers (HCWs) were stool-sampled and tested for E-ESBL colonization weekly. Several hypothetical acquisition routes of newborns-e.g. direct contact with family members and HCWs and indirect contact with other newborns through environmental contamination, colonization pressure, or transient hand carriage-were examined and compared using mathematical modeling and Bayesian inference. In our results, high E-ESBL acquisition rates were found, reaching > 70% for newborns, > 55% for family members, and > 75% for HCWs. Modeling analyses indicated transmission sources for newborn colonization to be species dependent. Health-care workers' route were selected for Klebsiella pneumoniae and Escherichia coli, with respective estimated transmission strengths of 0.05 (0.008; 0.14) and 0.008 (0.001; 0.021) ind-1 day-1. Indirect transmissions associated with ward prevalence, e.g. through hand carriage or environment, were selected for Enterobacter cloacae, E. coli, and K. pneumoniae (range 0.27-0.41 ind-1 day-1). Importantly, family members were not identified as transmission source. To conclude, E-ESBL acquisition sources are strongly species dependent. Escherichia coli and E. cloacae involve more indirect contamination, whereas K. pneumoniae also spreads through contact with colonized HCWs. These findings should help improve control measures to reduce in-hospital transmission.
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Affiliation(s)
- Mélanie Bonneault
- UMR1181 Biostatistique, Biomathématique, Pharmaco-épidémiologie et Maladies Infectieuses (B2PHI), Institut Pasteur, Université de Versailles-Saint-Quentin-en-Yvelines (UVSQ), Université Paris-Saclay, Inserm Paris, France
| | | | | | | | - Benoit Garin
- Institut Pasteur Madagascar, Antananarivo, Madagascar
| | - Sebastien Breurec
- Institut Pasteur de la Guadeloupe, Centre Hospitalier Universitaire de Pointe-à-Pitre/les Abymes, Pointe-à-Pitre, France, Guadeloupe, Faculté de Médecine, Pointe-à-Pitre, Guadeloupe
| | - Elisabeth Delarocque-Astagneau
- UMR1181 Biostatistique, Biomathématique, Pharmaco-épidémiologie et Maladies Infectieuses (B2PHI), Institut Pasteur, Université de Versailles-Saint-Quentin-en-Yvelines (UVSQ), Université Paris-Saclay, Inserm Paris, France
| | - Didier Guillemot
- UMR1181 Biostatistique, Biomathématique, Pharmaco-épidémiologie et Maladies Infectieuses (B2PHI), Institut Pasteur, Université de Versailles-Saint-Quentin-en-Yvelines (UVSQ), Université Paris-Saclay, Inserm Paris, France
| | - Zafitsara Zo Andrianirina
- Service de Pédiatrie et Néonatologie, Centre Hospitalier de Soavinandriana, Antananarivo, Madagascar
| | | | - Bich-Tram Huynh
- UMR1181 Biostatistique, Biomathématique, Pharmaco-épidémiologie et Maladies Infectieuses (B2PHI), Institut Pasteur, Université de Versailles-Saint-Quentin-en-Yvelines (UVSQ), Université Paris-Saclay, Inserm Paris, France
| | - Lulla Opatowski
- UMR1181 Biostatistique, Biomathématique, Pharmaco-épidémiologie et Maladies Infectieuses (B2PHI), Institut Pasteur, Université de Versailles-Saint-Quentin-en-Yvelines (UVSQ), Université Paris-Saclay, Inserm Paris, France
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da Silva KE, Baker S, Croda J, Nguyen TNT, Boinett CJ, Barbosa LS, Tetila A, Simionatto S. Risk factors for polymyxin-resistant carbapenemase-producing Enterobacteriaceae in critically ill patients: An epidemiological and clinical study. Int J Antimicrob Agents 2020; 55:105882. [PMID: 31923570 DOI: 10.1016/j.ijantimicag.2020.105882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/19/2019] [Accepted: 12/28/2019] [Indexed: 11/16/2022]
Abstract
This study aimed to assess the clinical impact and potential risk factors associated with polymyxin-resistant Enterobacteriaceae strains isolated from patients hospitalized in adult and neonatal intensive care units. A case-control study was conducted from September 2015 to January 2017. Antimicrobial susceptibility of polymyxin-resistant Enterobacteriaceae strains was determined by broth microdilution. The presence of resistance genes was evaluated by polymerase chain reaction and DNA sequencing. Renal failure [P=0.02, odds ratio (OR) 11.37, 95% confidence interval (CI) 1.0-128.63], use of a urinary catheter (P<0.01, OR 4.16, 95% CI 38.82-366.07), transfer between hospital units (P=0.03, OR 9.98, 95% CI 1.01-98.42), carbapenem use (P<0.01, OR 45.49, 95% CI 6.93-298.62) and surgical procedure (P<0.01, OR 16.52, 95% CI 2.83-96.32) were found to be risk factors for the acquisition of polymyxin-resistant strains in adult patients. For neonatal patients, use of a central venous catheter (P<0.01, OR 69.59, 95% CI 7.33-660.30) was the only risk factor associated with the acquisition of polymyxin-resistant strains. Analysis of the outcomes revealed that the mortality rate was significantly higher in adult (66.6%) and neonatal (23.5%) patients with polymyxin-resistant strains than in those with polymyxin-susceptible strains. In addition, carbapenem exposure (P<0.01, OR 50.93, 95% CI 2.26->999.999) was strongly associated with mortality. On the other hand, aminoglycoside use (P<0.03, OR 0.06, 95% CI 0.004-0.97) was a protective factor against mortality from polymyxin-resistant strains. Several risk factors were associated with polymyxin-resistant strains. The high mortality rates showed that acquisition of these strains is a predictor for unfavourable outcomes. Combination treatment with an aminoglycoside and polymyxin might be a better combination to improve patient outcomes.
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Affiliation(s)
- Kesia Esther da Silva
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil
| | - Stephen Baker
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK; Department of Medicine, Cambridge University, Cambridge, UK
| | - Julio Croda
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil; Fundação Osvaldo Cruz, Campo Grande, Mato Grosso do Sul, Brazil; Universidade Federal do Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - To Nguyen Thi Nguyen
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Christine J Boinett
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Leticia Spanivello Barbosa
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil
| | - Andyane Tetila
- Hospital Universitário de Dourados, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil
| | - Simone Simionatto
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil.
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Less contact isolation is more in the ICU: con. Intensive Care Med 2020; 46:1732-1734. [PMID: 31912205 DOI: 10.1007/s00134-019-05887-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/29/2019] [Indexed: 10/25/2022]
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Ludden C, Moradigaravand D, Jamrozy D, Gouliouris T, Blane B, Naydenova P, Hernandez-Garcia J, Wood P, Hadjirin N, Radakovic M, Crawley C, Brown NM, Holmes M, Parkhill J, Peacock SJ. A One Health Study of the Genetic Relatedness of Klebsiella pneumoniae and Their Mobile Elements in the East of England. Clin Infect Dis 2020; 70:219-226. [PMID: 30840764 PMCID: PMC6938978 DOI: 10.1093/cid/ciz174] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/27/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a human, animal, and environmental commensal and a leading cause of nosocomial infections, which are often caused by multiresistant strains. We evaluate putative sources of K. pneumoniae that are carried by and infect hospital patients. METHODS We conducted a 6-month survey on 2 hematology wards at Addenbrooke's Hospital, Cambridge, United Kingdom, in 2015 to isolate K. pneumoniae from stool, blood, and the environment. We conducted cross-sectional surveys of K. pneumoniae from 29 livestock farms, 97 meat products, the hospital sewer, and 20 municipal wastewater treatment plants in the East of England between 2014 and 2015. Isolates were sequenced and their genomes compared. RESULTS Klebsiella pneumoniae was isolated from stool of 17/149 (11%) patients and 18/922 swabs of their environment, together with 1 bloodstream infection during the study and 4 others over a 24-month period. Each patient carried 1 or more lineages that was unique to them, but 2 broad environmental contamination events and patient-environment transmission were identified. Klebsiella pneumoniae was isolated from cattle, poultry, hospital sewage, and 12/20 wastewater treatment plants. There was low genetic relatedness between isolates from patients/their hospital environment vs isolates from elsewhere. Identical genes encoding cephalosporin resistance were carried by isolates from humans/environment and elsewhere but were carried on different plasmids. CONCLUSION We identified no patient-to-patient transmission and no evidence for livestock as a source of K. pneumoniae infecting humans. However, our findings reaffirm the importance of the hospital environment as a source of K. pneumoniae associated with serious human infection.
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Affiliation(s)
- Catherine Ludden
- Department of Pathogen Molecular Biology, London School of Hygiene & Tropical Medicine, Hinxton
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton
| | - Danesh Moradigaravand
- Center for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Cambridge
| | - Dorota Jamrozy
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton
| | - Theodore Gouliouris
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge
- Clinical Microbiology and Public Health Laboratory, Public Health England, Cambridge
| | - Beth Blane
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge
| | - Plamena Naydenova
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge
| | | | - Paul Wood
- Royal (Dick) School of Veterinary Studies, University of Edinburgh, United Kingdom
| | - Nazreen Hadjirin
- Department of Veterinary Medicine, University of Cambridge, United Kingdom
| | - Milorad Radakovic
- Department of Veterinary Medicine, University of Cambridge, United Kingdom
| | - Charles Crawley
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge
| | - Nicholas M Brown
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge
- Clinical Microbiology and Public Health Laboratory, Public Health England, Cambridge
| | - Mark Holmes
- Department of Veterinary Medicine, University of Cambridge, United Kingdom
| | - Julian Parkhill
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton
| | - Sharon J Peacock
- Department of Pathogen Molecular Biology, London School of Hygiene & Tropical Medicine, Hinxton
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge
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Household carriage and acquisition of extended-spectrum β-lactamase-producing Enterobacteriaceae: A systematic review. Infect Control Hosp Epidemiol 2019; 41:286-294. [PMID: 31822301 DOI: 10.1017/ice.2019.336] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The epidemiology of ESBL-producing Enterobacteriaceae (ESBL-PE) has been extensively studied in hospitals, but data on community transmission are scarce. We investigated ESBL-PE cocarriage and acquisition in households using a systematic literature review. METHODS We conducted a systematic literature search to retrieve cross-sectional or cohort studies published between 1990 and 2018 evaluating cocarriage proportions and/or acquisition rates of ESBL-PE among household members, without language restriction. We excluded studies focusing on animal-to-human transmission or conducted in nonhousehold settings. The main outcomes were ESBL-PE cocarriage proportions and acquisition rates, stratified according to phenotypic or genotypic assessment of strain relatedness. Cocarriage proportions of clonally related ESBL-PE were transformed using the double-arcsine method and were pooled using a random-effects model. Potential biases were assessed manually. RESULTS We included 13 studies. Among 863 household members of ESBL-PE positive index cases, prevalence of ESBL-PE cocarriage ranged from 8% to 37%. Overall, 12% (95% confidence interval [CI], 8%-16%) of subjects had a clonally related strain. Those proportions were higher for Klebsiella pneumoniae (20%-25%) than for Escherichia coli (10%-20%). Acquisition rates of clonally related ESBL-PE among 180 initially ESBL-PE-free household members of a previously identified carrier ranged between 1.56 and 2.03 events per 1,000 person weeks of follow-up. We identified multiple sources of bias and high heterogeneity (I2, 70%) between studies. CONCLUSIONS ESBL-PE household cocarriage is frequent, suggesting intrafamilial acquisition. Further research is needed to evaluate the risk and control of ESBL-PE household transmission.
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Crellen T, Turner P, Pol S, Baker S, Nguyen Thi Nguyen T, Stoesser N, Day NPJ, Turner C, Cooper BS. Transmission dynamics and control of multidrug-resistant Klebsiella pneumoniae in neonates in a developing country. eLife 2019; 8:e50468. [PMID: 31793878 PMCID: PMC6977969 DOI: 10.7554/elife.50468] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022] Open
Abstract
Multidrug-resistant Klebsiella pneumoniae is an increasing cause of infant mortality in developing countries. We aimed to develop a quantitative understanding of the drivers of this epidemic by estimating the effects of antibiotics on nosocomial transmission risk, comparing competing hypotheses about mechanisms of spread, and quantifying the impact of potential interventions. Using a sequence of dynamic models, we analysed data from a one-year prospective carriage study in a Cambodian neonatal intensive care unit with hyperendemic third-generation cephalosporin-resistant K. pneumoniae. All widely-used antibiotics except imipenem were associated with an increased daily acquisition risk, with an odds ratio for the most common combination (ampicillin + gentamicin) of 1.96 (95% CrI 1.18, 3.36). Models incorporating genomic data found that colonisation pressure was associated with a higher transmission risk, indicated sequence type heterogeneity in transmissibility, and showed that within-ward transmission was insufficient to maintain endemicity. Simulations indicated that increasing the nurse-patient ratio could be an effective intervention.
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Affiliation(s)
- Thomas Crellen
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical MedicineMahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Paul Turner
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical MedicineMahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
- Cambodia-Oxford Medical Research UnitAngkor Hospital for ChildrenSiem ReapCambodia
| | - Sreymom Pol
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical MedicineMahidol UniversityBangkokThailand
- Cambodia-Oxford Medical Research UnitAngkor Hospital for ChildrenSiem ReapCambodia
| | - Stephen Baker
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
- Oxford University Clinical Research UnitCentre for Tropical MedicineHo Chi Minh CityViet Nam
| | - To Nguyen Thi Nguyen
- Oxford University Clinical Research UnitCentre for Tropical MedicineHo Chi Minh CityViet Nam
| | - Nicole Stoesser
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Nicholas PJ Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical MedicineMahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Claudia Turner
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical MedicineMahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
- Cambodia-Oxford Medical Research UnitAngkor Hospital for ChildrenSiem ReapCambodia
| | - Ben S Cooper
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical MedicineMahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
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Kim YA, Park YS, Kim B, Seo YH, Lee K. Prevalence and Risk Factors for Extended-Spectrum β-Lactamase-Producing Klebsiella pneumoniae Colonization in Intensive Care Units. Ann Lab Med 2019; 40:164-168. [PMID: 31650733 PMCID: PMC6821995 DOI: 10.3343/alm.2020.40.2.164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/26/2019] [Accepted: 10/01/2019] [Indexed: 11/19/2022] Open
Abstract
Active surveillance culture (ASC) can help detect hidden reservoirs, but the routine use of ASC for extended spectrum β-lactamase-producing Enterobacteriaceae is controversial in an endemic situation. We aimed to determine the prevalence and risk factors of extended spectrum β-lactamase-producing Klebsiella pneumoniae (EBSL-Kpn) colonization among intensive care unit (ICU)-admitted patients. Prospective screening of ESBL-Kpn colonization was performed for ICU-admitted patients within 48 hours for two months. A perirectal swab sample was inoculated on MacConkey agar supplemented with 2 µg/mL ceftazidime. ESBL genotype was determined by PCR-sequencing, and clonal relatedness was evaluated by pulsed-field gel electrophoresis (PFGE). The risk factors of ESBL-Kpn colonization were evaluated. The ESBL-Kpn colonization rate among the 281 patients at ICU admission was 6.4% (18/281), and blaCTX-M-15 was detected in all isolates. ESBL producers also showed resistance to fluoroquinolone (38.9%, 7/18). All isolates had the same ESBL genotype (blaCTX-M-15) and a highly clustered PFGE pattern, suggesting cross-transmission without a documented outbreak. In univariate analysis, the risk factor for ESBL-Kpn colonization over the control was the length of hospital stay (odds ratio=1.062; P=0.019). Routine use of ASC could help control endemic ESBL–Kpn for ICU patients.
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Affiliation(s)
- Young Ah Kim
- Department of Laboratory Medicine, National Health Insurance Service, Ilsan Hospital, Goyang, Korea.
| | - Yoon Soo Park
- Department of Internal Medicine, National Health Insurance Service, Ilsan Hospital, Goyang, Korea.,Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Banseok Kim
- Department of Laboratory Medicine, National Health Insurance Service, Ilsan Hospital, Goyang, Korea
| | - Young Hee Seo
- Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Kyungwon Lee
- Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea.,Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
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Less contact isolation is more in the ICU: not sure. Intensive Care Med 2019; 46:1735-1738. [DOI: 10.1007/s00134-019-05809-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
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Malande OO, Nuttall J, Pillay V, Bamford C, Eley B. A ten-year review of ESBL and non-ESBL Escherichia coli bloodstream infections among children at a tertiary referral hospital in South Africa. PLoS One 2019; 14:e0222675. [PMID: 31550295 PMCID: PMC6759190 DOI: 10.1371/journal.pone.0222675] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/03/2019] [Indexed: 12/04/2022] Open
Abstract
Introduction There are few studies describing Escherichia coli (E. coli) bloodstream infection (BSI) among children in Africa, yet E.coli is increasing in importance as a cause of antibiotic resistant infection in paediatric settings. Methods In this retrospective, descriptive study aspects of E. coli BSI epidemiology are described over a 10-year period including incidence risk, risk factors for extended-spectrum β-lactamase (ESBL)-producing E. coli BSI, antibiotic susceptibility of the bacterial isolates and outcome including risk factors for severe disease. Results There were 583 new E. coli BSI episodes among 217,483 admissions, an overall incidence risk of 2.7 events/1,000 hospital admissions. Of 455 of these E. coli BSI episodes that were analysed, 136 (29.9%) were caused by ESBL-producing isolates. Risk factors for ESBL-producing E. coli BSI included hospitalization in the 28-day period preceding E. coli BSI episodes, having an underlying chronic illness other than HIV infection at the time of the E. coli BSI and having a temperature of 38° Celsius or higher at the time of the E. coli BSI. None of the E. coli isolates were resistant to carbapenems or colistin. The mortality rate was 5.9% and admission to the intensive care unit was required in 12.3% of BSI episodes. Predictors of severe disease included age less than 1 month, hospitalization in the 28-day period preceding E. coli BSI and BSI without a definable focus. Conclusions These findings extend our understanding of E. coli BSI in a sub-Saharan African setting, provide useful information that can guide empiric treatment choices for community- and hospital-acquired BSI and help inform prevention strategies.
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Affiliation(s)
- Oliver Ombeva Malande
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - James Nuttall
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Vashini Pillay
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Colleen Bamford
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Microbiology, University of Cape Town, Cape Town, South Africa
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
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40
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Lucet JC, Zahar JR. Simplified control measures for ESBL-producing Enterobacteriacae? THE LANCET. INFECTIOUS DISEASES 2019; 19:1036-1037. [PMID: 31451422 DOI: 10.1016/s1473-3099(19)30412-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/09/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Jean-Christophe Lucet
- Université de Paris, Infection, Antimicrobiens, Modélisation, Évolution (IAME), Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France; *Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bichat, Infection Control Unit, F-75018 Paris, France.
| | - Jean-Ralph Zahar
- AP-HP, Hôpital Avicenne, Infection Control Unit, Bobigny, France
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Kluytmans-van den Bergh MFQ, Bruijning-Verhagen PCJ, Vandenbroucke-Grauls CMJE, de Brauwer EIGB, Buiting AGM, Diederen BM, van Elzakker EPM, Friedrich AW, Hopman J, Al Naiemi N, Rossen JWA, Ruijs GJHM, Savelkoul PHM, Verhulst C, Vos MC, Voss A, Bonten MJM, Kluytmans JAJW. Contact precautions in single-bed or multiple-bed rooms for patients with extended-spectrum β-lactamase-producing Enterobacteriaceae in Dutch hospitals: a cluster-randomised, crossover, non-inferiority study. THE LANCET. INFECTIOUS DISEASES 2019; 19:1069-1079. [PMID: 31451419 DOI: 10.1016/s1473-3099(19)30262-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/24/2019] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Use of single-bed rooms for control of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is under debate; the added value when applying contact precautions has not been shown. We aimed to assess whether an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae. METHODS We did a cluster-randomised, crossover, non-inferiority study on medical and surgical wards of 16 Dutch hospitals. During two consecutive study periods, either contact precautions in a single-bed room or contact precautions in a multiple-bed room were applied as the preferred isolation strategy for patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample (index patients). Eligible index patients were aged 18 years or older, had no strict indication for barrier precautions in a single-bed room, had a culture result reported within 7 days of culture and before discharge, and had no wardmate known to be colonised or infected with an ESBL-producing Enterobacteriaceae isolate of the same bacterial species with a similar antibiogram. Hospitals were randomly assigned in a 1:1 ratio by computer to one of two sequences of isolation strategies, stratified by university or non-university hospital. Allocation was masked for laboratory technicians who assessed the outcomes but not for patients, treating doctors, and infection-control practitioners enrolling index patients. The primary outcome was transmission of ESBL-producing Enterobacteriaceae to wardmates, which was defined as rectal carriage of an ESBL-producing Enterobacteriaceae isolate that was clonally related to the index patient's isolate in at least one wardmate. The primary analysis was done in the per-protocol population, which included patients who were adherent to the assigned room type. A 10% non-inferiority margin for the risk difference was used to assess non-inferiority. This study is registered with Nederlands Trialregister, NTR2799. FINDINGS 16 hospitals were randomised, eight to each sequence of isolation strategies. All hospitals randomised to the sequence single-bed room then multiple-bed room and five of eight hospitals randomised to the sequence multiple-bed room then single-bed room completed both study periods and were analysed. From April 24, 2011, to Feb 27, 2014, 1652 index patients and 12 875 wardmates were assessed for eligibility. Of those, 693 index patients and 9527 wardmates were enrolled and 463 index patients and 7093 wardmates were included in the per-protocol population. Transmission of ESBL-producing Enterobacteriaceae to at least one wardmate was identified for 11 (4%) of 275 index patients during the single-bed room strategy period and for 14 (7%) of 188 index patients during the multiple-bed room strategy period (crude risk difference 3·4%, 90% CI -0·3 to 7·1). INTERPRETATION For patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample, an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae. Non-inferiority of the multiple-bed room strategy might change the current single-bed room preference for isolation of patients with ESBL-producing Enterobacteriaceae and, thus, broaden infection-control options for ESBL-producing Enterobacteriaceae in daily clinical practice. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Marjolein F Q Kluytmans-van den Bergh
- Department of Infection Control, Amphia Hospital, Breda, Netherlands; Amphia Academy Infectious Disease Foundation, Amphia Hospital, Breda, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands.
| | - Patricia C J Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Anton G M Buiting
- Laboratory for Medical Microbiology and Immunology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Bram M Diederen
- Regional Laboratory of Public Health, Haarlem, Netherlands; Microvida Laboratory for Microbiology, Bravis Hospital, Roosendaal, Netherlands
| | | | - Alex W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joost Hopman
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nashwan Al Naiemi
- Department of Medical Microbiology and Infection Control, Ziekenhuisgroep Twente, Almelo/Hengelo, Netherlands
| | - John W A Rossen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Gijs J H M Ruijs
- Laboratory for Microbiology and Infectious Diseases, Isala Clinics, Zwolle, Netherlands
| | - Paul H M Savelkoul
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Carlo Verhulst
- Microvida Laboratory for Microbiology, Amphia Hospital, Breda, Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - Andreas Voss
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Medical Microbiology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Jan A J W Kluytmans
- Department of Infection Control, Amphia Hospital, Breda, Netherlands; Microvida Laboratory for Microbiology, Amphia Hospital, Breda, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
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Birgand G, Zahar JR, Lucet JC. Insight Into the Complex Epidemiology of Multidrug-Resistant Enterobacteriaceae. Clin Infect Dis 2019; 66:494-496. [PMID: 29020395 DOI: 10.1093/cid/cix826] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 09/14/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Gabriel Birgand
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Jean-Ralph Zahar
- INSERM, IAME, UMR 1137, and Université Paris Diderot, Sorbonne Paris Cité, Paris.,Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Infection Control Unit, Bobigny
| | - Jean-Christophe Lucet
- INSERM, IAME, UMR 1137, and Université Paris Diderot, Sorbonne Paris Cité, Paris.,AP-HP, Hôpital Bichat-Claude Bernard, Infection Control Unit, Paris, France
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Prevel R, Boyer A, M’Zali F, Cockenpot T, Lasheras A, Dubois V, Gruson D. Extended spectrum beta-lactamase producing Enterobacterales faecal carriage in a medical intensive care unit: low rates of cross-transmission and infection. Antimicrob Resist Infect Control 2019; 8:112. [PMID: 31333839 PMCID: PMC6617905 DOI: 10.1186/s13756-019-0572-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022] Open
Abstract
Background Extended-spectrum beta-lactamases-producing Enterobacterales (ESBL-E) are disseminating worldwide especially in Intensive Care Units (ICUs) and are responsible for increased health costs and mortality. The aims of this work were to study ESBL-E dissemination in ICU and to assess the impact of ESBL-E fecal carriage on subsequent infections during a non-outbreak situation. Methods We therefore screened every patient at admission then once a week in a medical ICU between January and June 2015. Each ESBL-E isolate was characterized by ESBL genes PCR amplification and the clonal dissemination was assessed by Pulsed-Field Gel Electrophoresis (PFGE). Results Among the 608 screened patients, 55 (9%) were colonized by ESBL-E. Forty-four isolates were available for further analysis. Most of them (43/44, 98%) contained a ESBL gene from the CTX-M group. Only one case of ESBL-E cross-transmission occurred, even for acquired ESBL-E colonization. Subsequent infection by ESBL-E occurred in 6/55 (11%) patients and infecting ESBL-E strains were the colonizing ones. ESBL-E faecal carriage had a negative predictive value of 100% and a positive predictive value of 40% to predict ESBL-E ventilator associated-pneumonia (VAP). Alternatives to carbapenems consisting in piperacillin-tazobactam, ceftolozane-tazobactam and ceftazidime-avibactam were all active on this panel of ESBL-E. Conclusions ESBL-E expansion and acquisition in ICU in a non-outbreak situation are not any more fully explained by cross-transmission. Mechanisms underlying ESBL-E dissemination in ICU are still to investigate. Interestingly, as far as we know, our study demonstrates for the first time by PFGE that the colonizing strain is indeed the infecting one in case of subsequent ESBL-E infection. Nevertheless, subsequent ESBL-E infection remains a rare event conferring poor positive predictive value for ESBL-E colonization to predict ESBL-E VAP. Relevance of systematic ESBL-E faecal screening at ICU admission and during ICU stay needs further investigation.
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Affiliation(s)
- Renaud Prevel
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
| | - Alexandre Boyer
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
| | - Fatima M’Zali
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
| | | | | | - Véronique Dubois
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
- Bacteriology laboratory, CHU Bordeaux, F-33000 Bordeaux, France
| | - Didier Gruson
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
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Abstract
Hypervirulent K. pneumoniae (hvKp) is an evolving pathotype that is more virulent than classical K. pneumoniae (cKp). hvKp usually infects individuals from the community, who are often healthy. Infections are more common in the Asian Pacific Rim but are occurring globally. hvKp infection frequently presents at multiple sites or subsequently metastatically spreads, often requiring source control. hvKp has an increased ability to cause central nervous system infection and endophthalmitis, which require rapid recognition and site-specific treatment. The genetic factors that confer hvKp's hypervirulent phenotype are present on a large virulence plasmid and perhaps integrative conjugal elements. Increased capsule production and aerobactin production are established hvKp-specific virulence factors. Similar to cKp, hvKp strains are becoming increasingly resistant to antimicrobials via acquisition of mobile elements carrying resistance determinants, and new hvKp strains emerge when extensively drug-resistant cKp strains acquire hvKp-specific virulence determinants, resulting in nosocomial infection. Presently, clinical laboratories are unable to differentiate cKp from hvKp, but recently, several biomarkers and quantitative siderophore production have been shown to accurately predict hvKp strains, which could lead to the development of a diagnostic test for use by clinical laboratories for optimal patient care and for use in epidemiologic surveillance and research studies.
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Affiliation(s)
- Thomas A Russo
- Department of Medicine, University at Buffalo-State University of New York, Buffalo, New York, USA
- Department of Microbiology and Immunology, University at Buffalo-State University of New York, Buffalo, New York, USA
- The Witebsky Center for Microbial Pathogenesis, University at Buffalo-State University of New York, Buffalo, New York, USA
- The Veterans Administration Western New York Healthcare System, Buffalo, New York, USA
| | - Candace M Marr
- Department of Medicine, University at Buffalo-State University of New York, Buffalo, New York, USA
- Erie County Medical Center, Buffalo, New York, USA
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Persisting intrahospital transmission of multidrug-resistant Klebsiella pneumoniae and challenges for infection control. Infect Control Hosp Epidemiol 2019; 40:904-909. [PMID: 31184564 DOI: 10.1017/ice.2019.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the past several decades, the incidence of Klebsiella pneumoniae harboring resistance mechanisms against multiple antibiotic agents has increased on a global scale. We discuss reasons for ongoing transmission of multidrug-resistant K. pneumoniae in healthcare settings, which has resulted in the successful spread and establishment of this pathogen. It is now one of the most important causes of healthcare-associated infections worldwide.
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Abstract
PURPOSE OF REVIEW Two pathotypes of Klebsiella pneumoniae cause human infections, classical (cKp) and hypervirulent (hvKp) K. pneumoniae. The present understanding of genetic elements, the need for an accurate test to identify hvKp, the clinical implications of infection, the knowledge gap on how and why hvKp colonization transitions to infection, and potential infection prevention and control issues for hvKp are discussed. RECENT FINDINGS Infections because of hvKp are increasingly recognized worldwide. Its ability to cause organ and life-threatening disease in healthy individuals from the community merits concern, which has been magnified by increasing descriptions of multiply drug-resistant (MDR) and extensively drug-resistant (XDR) strains. Increased capsule and siderophore production by hvKp relative to cKp are critical virulence traits. Asians are most commonly infected, but whether this is mediated by a genetic susceptibility, or increased exposure and colonization is unknown. Specific studies about the epidemiology and transmission of hvKp are lacking, but precautions are appropriate for MDR/XDR strains and perhaps all infected/colonized individuals. SUMMARY hvKp is evolving into an increasingly concerning pathogen, in part because of the development of XDR strains. An accurate test to identify hvKp is needed for optimal clinical care, epidemiological, and research studies. An improved understanding of how infection develops, if a genetic susceptibility exists, and appropriate infection prevention and control measures also are needed.
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Prevel R, Boyer A, M'Zali F, Lasheras A, Zahar JR, Rogues AM, Gruson D. Is systematic fecal carriage screening of extended-spectrum beta-lactamase-producing Enterobacteriaceae still useful in intensive care unit: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:170. [PMID: 31088542 PMCID: PMC6518813 DOI: 10.1186/s13054-019-2460-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). ESBL-E dissemination was first due to outbreaks in hospital settings which led to the implementation of systematic fecal carriage screening to improve hygiene procedures by contact precautions. ESBLs have since spread in the community, and the relevance of contact precautions is questioned. ESBL-E dissemination led to an overuse of carbapenems triggering the emergence of carbapenem-resistant Enterobacteriaceae. Empirical antimicrobial therapy based on ESBL-E fecal carriage has been proposed but is debated as it could increase the consumption of carbapenems among ESBL-E carriers without any clinical benefit. Finally, selective decontamination among ESBL-E fecal carriers is evoked to decrease the risk for subsequent ESBL-E infection, but its efficacy remains debated. We propose to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in adult ICU. METHODS Every article focusing on ESBL-E and ICU available on the MEDLINE database was assessed. Articles were included if focusing on cross-transmission, efficacy of hygiene procedures, link between ESBL-E colonization and infection or guidance of empirical therapy or selective decontamination efficacy. RESULTS Among 330 articles referenced on PubMed, 39 abstracts were selected for full-text assessment and 25 studies were included. Systematic screening of ESBL-E fecal carriage to guide contact precautions do not seem to decrease the rate of ESBL-E cross-transmission. It has a very good negative predictive value for subsequent ESBL-E infections but a positive predictive value between 40 and 50% and so does not help to spare carbapenems. Cessation of ESBL-E carriage systematic screening could decrease the use of carbapenems in ICU without any clinical harm. Nevertheless, further studies are needed to validate these results from monocentric before-after study. Selective decontamination strategy applied to ESBL-E fecal carriers could be helpful, but available data are conflicting. CONCLUSION Current knowledge lacks of high-quality evidence to strongly recommend in favor of or against a systematic ESBL-E fecal carriage screening policy for ICU patients in a non-outbreak situation. Further evaluation of selective decontamination or fecal microbiota transplantation among ESBL-E fecal carriers is needed.
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Affiliation(s)
- Renaud Prevel
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France. .,UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France. .,, Bordeaux, France.
| | - Alexandre Boyer
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
| | - Fatima M'Zali
- UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France
| | - Agnès Lasheras
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France
| | - Jean-Ralph Zahar
- Unité INSERM - IAME UMR 1137, Université Paris-13, Bobigny, France
| | - Anne-Marie Rogues
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France.,Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, UMR 1219, F-33000, Bordeaux, France
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
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Duval A, Obadia T, Boëlle PY, Fleury E, Herrmann JL, Guillemot D, Temime L, Opatowski L. Close proximity interactions support transmission of ESBL-K. pneumoniae but not ESBL-E. coli in healthcare settings. PLoS Comput Biol 2019; 15:e1006496. [PMID: 31145725 PMCID: PMC6542504 DOI: 10.1371/journal.pcbi.1006496] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 04/08/2019] [Indexed: 11/19/2022] Open
Abstract
Antibiotic-resistance of hospital-acquired infections is a major public health issue. The worldwide emergence and diffusion of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, including Escherichia coli (ESBL-EC) and Klebsiella pneumoniae (ESBL-KP), is of particular concern. Preventing their nosocomial spread requires understanding their transmission. Using Close Proximity Interactions (CPIs), measured by wearable sensors, and weekly ESBL-EC-and ESBL-KP-carriage data, we traced their possible transmission paths among 329 patients in a 200-bed long-term care facility over 4 months. Based on phenotypically defined resistance profiles to 12 antibiotics only, new bacterial acquisitions were tracked. Extending a previously proposed statistical method, the CPI network's ability to support observed incident-colonization episodes of ESBL-EC and ESBL-KP was tested. Finally, mathematical modeling based on our findings assessed the effect of several infection-control measures. A potential infector was identified in the CPI network for 80% (16/20) of ESBL-KP acquisition episodes. The lengths of CPI paths between ESBL-KP incident cases and their potential infectors were shorter than predicted by chance (P = 0.02), indicating that CPI-network relationships were consistent with dissemination. Potential ESBL-EC infectors were identified for 54% (19/35) of the acquisitions, with longer-than-expected lengths of CPI paths. These contrasting results yielded differing impacts of infection control scenarios, with contact reduction interventions proving less effective for ESBL-EC than for ESBL-KP. These results highlight the widely variable transmission patterns among ESBL-producing Enterobacteriaceae species. CPI networks supported ESBL-KP, but not ESBL-EC spread. These outcomes could help design more specific surveillance and control strategies to prevent in-hospital Enterobacteriaceae dissemination.
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Affiliation(s)
- Audrey Duval
- Equipe PheMI, unité B2PHI, Inserm, Université de Versailles Saint Quentin, Institut Pasteur,Paris, France
| | - Thomas Obadia
- Malaria: Parasites & Hosts Unit, Department of Parasites & Insect Vectors, Institut Pasteur,Paris, France
- Institut Pasteur—Bioinformatics and Biostatistics Hub—C3BI, USR 3756 IP CNRS—Paris, France
| | - Pierre-Yves Boëlle
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, PARIS France
| | - Eric Fleury
- Univ Lyon, Cnrs, ENS de Lyon, Inria, UCB Lyon 1, LIP UMR 5668, Lyon, FRANCE
| | - Jean-Louis Herrmann
- INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France AP-HP, Service de Microbiologie, Hôpital Raymond Poincaré, Garches, France
| | - Didier Guillemot
- Equipe PheMI, unité B2PHI, Inserm, Université de Versailles Saint Quentin, Institut Pasteur,Paris, France
| | - Laura Temime
- Laboratoire MESuRS, Conservatoire national des Arts et Métiers, Paris, France
- Institut Pasteur, Cnam, unité PACRI, Paris, France
| | - Lulla Opatowski
- Equipe PheMI, unité B2PHI, Inserm, Université de Versailles Saint Quentin, Institut Pasteur,Paris, France
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High prevalence of CTX-M-1 group in ESBL-producing enterobacteriaceae infection in intensive care units in southern Chile. Braz J Infect Dis 2019; 23:102-110. [PMID: 31028724 PMCID: PMC9425662 DOI: 10.1016/j.bjid.2019.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/12/2019] [Accepted: 03/17/2019] [Indexed: 12/31/2022] Open
Abstract
Enterobacteria-producing extended-spectrum β-lactamases (ESBL) play an important role in healthcare infections, increasing hospitalization time, morbidity and mortality rates. Among several ESBLs that emerge from these pathogens, CTX-M-type enzymes had the most successful global spread in different epidemiological settings. Latin America presents high prevalence of CTX-M-2 in ESBL-producing enterobacterial infections with local emergence of the CTX-M-1 group. However, this high prevalence of the CTX-M-1 group has not yet been reported in Chile. The aim of this study was to identify ESBLs among enterobacteria isolated from clinical samples of critically ill patients from southern Chile. One-hundred thirty seven ESBL-producing bacteria were isolated from outpatients from all critical patient units from Hernán Henríquez Aravena Hospital. Phenotype characterization was performed by antibiogram, screening of ESBL, and determination of minimum inhibitory concentration (MIC). PCR was used for genetic confirmation of resistance. Molecular typing was performed by ERIC-PCR. ESBL-producing isolates were identified as Klebsiella pneumoniae (n = 115), Escherichia coli (n = 18), Proteus mirabilis (n = 3), and Enterobacter cloacae (n = 1), presenting multidrug resistance profiles. PCR amplification showed that the strains were positive for blaSHV (n = 111/81%), blaCTX-M-1 (n = 116/84.7%), blaTEM (n = 100/73%), blaCTX-M-2 (n = 28/20.4%), blaCTX-M-9 (0.7%), blaPER-1 (0.7%), and blaGES-10 (0.7%). The multiple production of ESBL was observed in 93% of isolates, suggesting high genetic mobility independent of the clonal relationship. The high frequency of the CTX-M-1 group and a high rate of ESBL co-production are changing the epidemiology of the ESBL profile in Chilean intensive care units. This epidemiology is a constant and increasing challenge, not only in Chile, but worldwide.
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50
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Otter JA, Natale A, Batra R, Tosas Auguet O, Dyakova E, Goldenberg SD, Edgeworth JD. Individual- and community-level risk factors for ESBL Enterobacteriaceae colonization identified by universal admission screening in London. Clin Microbiol Infect 2019; 25:1259-1265. [PMID: 30849431 DOI: 10.1016/j.cmi.2019.02.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 02/12/2019] [Accepted: 02/23/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES We evaluated risk factors for gastrointestinal carriage of Enterobacteriaceae which produce extended-spectrum β-lactamases (ESBL-E), including individual-level variables such as antibiotic use and foreign travel, and community-level variables such as housing and deprivation. METHODS In an observational study in 2015, all patients admitted to a London hospital group were approached to be screened for ESBL-E carriage using rectal swabs for 4 months. Patients completed a risk factor questionnaire. Those with a residential postcode in the local catchment area were linked to a database containing community-level risk factor data. Risk factors for ESBL-E carriage were determined by binary logistic regression. RESULTS Of 4006 patients, 360 (9.0%) carried ESBL-E. Escherichia coli was the most common organism (77.8%), and CTX-M-type ESBLs were the most common genes (57.9% CTX-M-15 and 20.7% CTX-M-9). In multivariable analysis, risk factors for phenotypic ESBL-E among the 1633 patients with a residential postcode within the local catchment area were: travel to Asia (OR 4.4, CI 2.5-7.6) or Africa (OR 2.4, CI 1.2-4.8) in the 12 months prior to admission, two or more courses of antibiotics in the 6 months prior to admission (OR 2.0, CI 1.3-3.0), and residence in a district with a higher-than-average prevalence of overcrowded households (OR 1.5, CI 1.05-2.2). . CONCLUSIONS Both individual and community variables were associated with ESBL-E carriage at hospital admission. The novel observation that household overcrowding is associated with ESBL-E carriage requires confirmation, but raises the possibility that targeted interventions in the community could help prevent transmission of antibiotic-resistant Gram-negative bacteria.
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Affiliation(s)
- J A Otter
- Centre for Clinical Infection and Diagnostics Research (CIDR), Department of Infectious Diseases, King's College London & Guy's and St Thomas' NHS Foundation Trust, London, UK; NIHR Health Protection Research Unit (HPRU) in HCAIs and AMR at Imperial College London, Imperial College Healthcare NHS Trust, Infection Prevention and Control, London, UK.
| | - A Natale
- Centre for Clinical Infection and Diagnostics Research (CIDR), Department of Infectious Diseases, King's College London & Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R Batra
- Centre for Clinical Infection and Diagnostics Research (CIDR), Department of Infectious Diseases, King's College London & Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - O Tosas Auguet
- Centre for Clinical Infection and Diagnostics Research (CIDR), Department of Infectious Diseases, King's College London & Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Dyakova
- Centre for Clinical Infection and Diagnostics Research (CIDR), Department of Infectious Diseases, King's College London & Guy's and St Thomas' NHS Foundation Trust, London, UK; NIHR Health Protection Research Unit (HPRU) in HCAIs and AMR at Imperial College London, Imperial College Healthcare NHS Trust, Infection Prevention and Control, London, UK
| | - S D Goldenberg
- Centre for Clinical Infection and Diagnostics Research (CIDR), Department of Infectious Diseases, King's College London & Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J D Edgeworth
- Centre for Clinical Infection and Diagnostics Research (CIDR), Department of Infectious Diseases, King's College London & Guy's and St Thomas' NHS Foundation Trust, London, UK
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